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Based on document review and interview, it was determined the Hospital failed to ensure the provision of the safe use of restraints. Therefore, the Condition of Participation 42 CFR 482.13, Patient Rights, was not met. This has the potential to affect all patients who require the use of non-violent and/or violent/self-destructive restraint/seclusion.

Findings include:

1. The Hospital failed to ensure non-violent restraint orders were signed within 24 hours, in accordance with the Hospital's policy. See A-168A

2. The Hospital failed to ensure physician orders for violent or self -destructive restraint were obtained per policy. See A-168B

3. The Hospital failed to ensure restraint orders weren't written on an as needed basis (PRN). See A-169

4. The Hospital failed to ensure violent or self-destructive monitoring was performed, in accordance with the Hospital's policy. See A-175

5. The Hospital failed to ensure its restraint seclusion policy included the training requirements for physicians who order restraints/seclusion. See A-176

Based on document review and interview, it was determined for 1 of 2 patients (Pt #18) reviewed for grievances, the Hospital failed to ensure grievances were investigated, in accordance with the Hospital's policy. This has the potential to affect all inpatients and outpatients serviced by the Hospital.

Findings include:

1. The Hospital policy titled, "Customer Complaints/Grievances" (reviewed by the Hospital on 9/2018) was reviewed on 3/14/19 at approximately 9:00 AM. The policy stated, "Grievance: ... A complaint that is cannot be resolved at the time of the complaint... that is postponed for later resolution... that is referred to other staff for later resolution... that requires investigation... that requires further actions for resolution... or if it involves quality of care issues... will address grievances within 2 business days of receiving them... The complainant will be offered resolution actions in writing within 7 business days of receipt of the grievance... When the investigation has concluded and resolution actions have been decided upon, the complainant will be informed promptly in writing... "

2. The complaint/grievance log for January 2019 to March 2019 was reviewed on 3/14/19 at approximately 8:15 AM. The log stated that Pt #18 reported a complaint/grievance on 1/16/19 for "Treatment issues" with an event date of 12/23/18. The log stated, "Grievance initiated" and was marked "Y" (Yes). The Grievance follow-up was reviewed with the Director of Quality Management (E#3) at 8:50 AM. The follow-up lacked a resolution letter.

3. An interview was conducted with E#3 during the grievance review of Pt #18. E#3 stated, "I looked at it as a billing issue. I can see now that there was a question as to whether the doctor diagnosed (Pt #18) right and I had (a physician) review the record. I should have sent a resolution letter and I didn't. It was really two issues, with one being (Pt #18's) care."

A. Based on document review and interview it was determined in 2 of 4 patients' (Pt.#14, Pt #15) records reviewed for non-violent restraints, the Hospital failed to ensure non-violent restraint orders were signed within 24 hours, in accordance with the Hospital's policy. This has the potential to affect all patients who require the use of non-violent restraints at this Hospital.

Findings include:

1. The hospital policy titled, "Restraints, Use of" (revision date by the Hospital on 3/2018) was reviewed on 3/14/19 at approximately 2:00 PM. On page 3, the policy stated, "Protective Restraints-2 Point Only... 1. The order must originate from the physician...the original order must be signed by the physician within 24 hours... 3. Determine equipment needed based upon physician's specific order. Available equipment might be: Geri chair, soft limb restraints..."

2. Pt #14 Date of admission: 3/1/19
Diagnoses: Hypokalemia and Fall. Pt #14's record was reviewed on 3/14/19 at approximately 1:30 PM. On 3/8/19 at 9:30 PM, there was a physician order written on the "PHYSICIAN ORDERS" form by the nurse stating, "Place patient in soft medical restraints for safety precautions." On 3/8/19 at 9:30 PM, there was a second physician order written by the nurse on the pre printed "PHYSICIAN ORDERS PROTECTIVE RESTRAINTS" form that indicated under the categories Reason for Restraint Type Used: Protective the box marked "Soft limb--wrist ankle (Circle)" was check marked and "Soft Limb--wrist" was circled. As of 3/15/19 at approximately 1:00 PM, neither order had been signed by a Physician.

3. Pt #15 Date of admission: 2/7/19
Diagnosis: Colon Resection. Pt #15's record was reviewed on 3/14/19 at approximately 3:00 PM. On 2/13/19 at 9:45 AM, the pre printed "PHYSICIANS ORDER PROTECTIVE RESTRAINTS" form was utilized for restraint order. Under the Categories Reason for restraint: Type Used: Protective the Geri chair PRN (as needed) box was check marked. On 2/13/19 at 8:06 PM and at 10:31 PM, Pt #15's nursing "Daily Focus Assessment Report" documentation stated, "Protective/Locked Restraints... Geri-chair w/tray (with tray)". The order was not authenticated until 2/27/19, which was after Pt #15 was discharged from the Hospital.

4. An interview was conducted with the Director of Obstetrics (E#13) on 3/14/19 at approximately 3:30 PM. E#13 reviewed the record of Pt #14 and Pt #15 and verbally agreed the restraint orders had not been signed within the required 24 hours and should have been.


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B. Based on document review and interview, it was determined in 4 of 4 patients (Pt #11, Pt #31, Pt #32, and Pt #33) Emergency Department (ED) records reviewed, whom were restrained for violent or self-destructive behavior, the Hospital failed to ensure physician orders for violent or self-destructive behavior restraints were obtained per policy. This has the potential to affect all patients whom present to the ED and require the use of restraints for violent or self-destructive behavior.

Findings Include:

1. The policy titled "Restraints, Use of" (reviewed by the Hospital on 3/2018) was reviewed on 03/15/19 at approximately 10:00 AM. On page 1, the policy noted, "Policy .... use of restraints of any kind must be applied only upon the order of a physician ..."

2. Pt #11 Date of Admission: 02/08/19
Diagnosis: Schizoaffective Disorder Uncontrolled. The clinical record was reviewed on 03/14/18 at approximately 3:30 PM. The record noted that Pt #3 arrived at the ED with the police on 02/08/19 at 5:23 AM. Nursing notes indicated that at 7:20 AM, Pt #11 was placed in locked restraints on the right wrist and left ankle. At 7:31 AM, Pt #11 was placed in 4 point locked restraints. At 12:06 PM, the restraints were removed. The record lacked documentation of the restraint orders.

3. Pt #31 Date of Admission: 01/01/19
Diagnosis: Alcohol Intoxication. The clinical record was reviewed on 03/15/19 at approximately 11:00 AM. The record noted that Pt #31 arrived to the ED by ambulance on 01/01/19 at 1:21 AM. The nursing notes indicated that on 1/01/19 at 2:00 AM, Pt #31 was placed in 4 point locked restraints. The left wrist restraint was removed at 3:30 AM and the remaining restraints were removed at 4:30 AM. The record lacked documentation of a restraint order.

4. Pt #32 Date of Admission: 02/17/19
Diagnosis: Alcohol Intoxication. The clinical record was reviewed on 03/15/19 at approximately 11:15 AM. The record noted that Pt #32 arrived at the ED with the police on 02/17/19 at 12:45 AM. The nursing notes indicated that on 2/17/19 at 1:00 AM, Pt #32 was placed in 4 point locked restraints. The right ankle restraint was removed at 2:44 AM and the remaining restraints were removed at 4:50 AM. The record lacked documentation of a restraint order.

5. Pt #33 Date of Admission: 03/05/19
Diagnosis: Anxiety/ Situational Crisis. The clinical record was reviewed on 03/15/19 at approximately 11:30 AM. The record noted that Pt #33 arrived at the ED with the police on 03/05/19 at 7:43 PM. The nursing notes indicated that on 3/15/19 at 8:15 PM, Pt #33 was placed in 4 point locked restraints. The restraints were removed at 9:45 PM. The record lacked documentation of a restraint order.

6. An interview was conducted with the Emergency Room Director (E#19) on 03/15/19 at approximately 12:00 PM. E #19 reviewed the records of Pt #11, Pt #31, Pt #32, and Pt #33 and verbally agreed "They do not have documentation of restraint orders and should have."

Based on document review and interview, it was determined in 1 of 4 patients' (Pt #15) records reviewed for non-violent restraints, The Hospital failed to ensure restraint orders weren't written on an as needed basis (PRN). This has the potential to affect all patients who require the use of non-violent restraints at this Hospital.

1. The hospital policy titled, "Restraints, Use of" (revision date by the Hospital on 3/2018) was reviewed on 3/14/19 at approximately 2:00 PM. On page 3, the policy stated, "Protective Restraints-2 Point Only... 1. The order must originate from the physician...the original order must be signed by the physician within 24 hours... 3. Determine equipment needed based upon physician's specific order. Available equipment might be: Geri chair, soft limb restraints..."

2. The Hospital pre printed "PHYSICIAN ORDERS PROTECTIVE RESTRAINTS" form (Revised by the Hospital June 2012) was reviewed on 3/14/19. Under the Categories Reason for Restraint: Type Used: Protective were two items listed "Soft limb--wrist ankle (Circle)" and "Geri chair PRN" with a box next to both of these items for check marking.

3. Pt #15 Date of admission: 2/7/19
Diagnosis: Colon Resection. Pt #15's record was reviewed on 3/14/19 at approximately 3:00 PM. On 2/13/19 at 9:45 AM, the pre printed "PHYSICIANS ORDER PROTECTIVE RESTRAINTS" form was utilized for restraint order. Under the Categories Reason for restraint: Type Used: Protective the Geri chair PRN (as needed) box was check marked. On 2/13/19 at 8:06 PM and at 10:31 PM, Pt #15's nursing "Daily Focus Assessment Report" documentation stated, "Protective/Locked Restraints... Geri-chair w/tray (with tray)".

4. An interview was conducted with the Director of Obstetrics (E#13) on 3/14/19 at approximately 3:30 PM. E#13 reviewed the record of Pt #15 and verbally agreed the restraint order was written as needed (PRN).

Based on document review and interview, it was determined in 1 of 4 patients' (Pt #11) records reviewed with violent restraint use in the Emergency Department (ED), the Hospital failed to ensure that patient monitoring was performed in accordance with its policy. This has the potential to affect all patients that are restrained.

Findings include:

1. The policy titled "Restraints, Use of" (reviewed by the Hospital on 3/2018) was reviewed on 03/15/19 at approximately 10:00 AM. On page 7, the policy noted "... Procedure... g) The patient in locked restraints is observed every 15 minutes (Behavioral checks) ..."

2. Pt #11 Date of Admission: 02/08/19
Diagnosis: Schizoaffective Disorder Uncontrolled. The clinical record was reviewed on 03/14/18 at approximately 3:30 PM. The record noted that Pt #11 arrived at the ED with police on 02/08/19 at 5:23 AM. Nursing notes indicated that on 2/8/19 at 7:20 AM, Pt #11 was placed in locked restraints on the right wrist and left ankle. At 7:31 AM, the patient was placed in 4 point locked restraints. At 12:06 PM, the restraints were removed. Between 7:31 AM and 12:06 PM, the record lacked every 15 minute observations, as follows:

8:20 AM (49 minutes after 4 point restraints were applied)
8:57 AM (37 minutes later)
9:25 AM (1 hour and 5 minutes later)
9:34 AM (9 minutes later)
11:15 AM (1 hour 35 minutes later)
12:06 PM (51 minutes later)

3. An interview was conducted with the Emergency Room Director (E#19) on 03/15/19 at approximately 12:00 PM. E #19 reviewed Pt #11's record and verbally agreed Pt #11 had not been observed every 15 minutes according to policy.

Based on document review and interview, it was determined for 4 of 4 Physicians (Medical Doctor- MD#2, MD#3, MD#5, and MD#6), whom can order restraint and/or seclusion, the Hospital failed to ensure its restraint seclusion policy, included the training requirements for physicians who order restraints/seclusion. This has the potential to affect all patients who may require the use of violent and/or non-violent restraint and/or seclusion.

Findings include:

1. The Hospital policy titled, "Restraints, Use of" (reviewed by the Hospital on 3/2018) was reviewed on 3/14/19 at approximately 3:00 PM. The policy lacked the training requirements for Physicians whom order restraint/seclusion.

2. The Physician credential files were reviewed on 3/14/19 at approximately 12:20 PM, with the Medial Staff Specialist (E#9). The following credentialing files for the Physicians whom can order the use of restraint and/or seclusion, lacked documentation of a working knowledge of the Hospital's restraint/seclusion policy:
a. MD#2 (Hospitalist) with an initial appointment of 6/21/17.
b. MD#3 (Hospitalist) with an reappointment date of 6/21/17.
a. MD#5 (Emergency Room) with an reappointment date of 1/4/18.
b. MD#6 (Emergency Room) with an reappointment date of 6/21/17.

3. An interview was conducted with E#9 during the credential file review. E#9 stated, "We don't have anything on restraint/seclusion training for our physicians."

4. An interview was conducted with the Director of Education (E#8) on 3/14/19 at approximately 3:30 PM. E#9 verbally agreed the Hospital's restraint/seclusion policy does not address the training requirements for physicians and that the physicians do not have any restraint/seclusion training at this time.

Based on document review and interview, it was determined for 1 of 2 CRNAs (Certified Registered Nurse Anesthetist- CRNA#2), the Hospital failed to ensure CRNA privileges accurately reflected the scope of anesthesia services provided by the Hospital. This has the potential to affect all patients who require anesthesia services.

Findings include:

1. CRNA #2's credential file was reviewed on 3/14/19 at approximately 12:20 PM with the Medical Staff Specialist (E#9). CRNA #2's privilege list included requests for the following examples of privileges, which the Hospital does not provide:
a. Regional Techniques: Eye block (peribullar, retrobulbar) and Intracapular.
b. Procedures and Special Techniques: Placement of right heart and pulmonary artery lines, Cardiopulmonary bypass technique, Autotransfusion technique; Processed EEG (electroencephalogram)

2. An interview was conducted with E#9 during the credential file review. E#9 stated, "It looks like (CRNA#2) just put a line down all the privilege requests and they (the physician supervisor) didn't catch it. We don't do those procedures here and they shouldn't have been approved as privileges for (CRNA#2).

Based on document review and interview, it was determined for 1 of 3 (Pt #1) adverse event patients reviewed for completion of orders, the Hospital failed to ensure physician orders were completed, as ordered. This has the potential to affect all inpatients and outpatients serviced by the Hospital.

Findings include:

1. Pt #1 Admitted 3/4/18 Discharged: 3/5/18 Diagnoses: Abdominal Pain and Systemic Inflammatory Response Syndrome).
Pt #1's record was reviewed 3/12/19 through 3/13/19 with the Director of Obstetrics (E#13).
a. On 3/5/18 at 6:45 AM, there was a physician telephone order for blood culture testing times two, a lactic acid level, troponin level, Vancomycin and Zosyn (antibiotics) per Pharmacy dosing, and a Bicarbonate drip per Pharmacy. There was no documentation of the blood cultures and lactic acid level being performed. There was no documentation the Zosyn was initiated.
b. On 3/5/18 at 7:15 AM, there was a physician order to give Dextrose 50 intravenous push followed by 12 units of regular insulin. The record lacked documentation these orders were followed.

2. An interview was conducted with E#13 on 3/12/19 at approximately 10:30 AM. E#13 verbally agreed the 3/5/18 6:45 AM orders for blood cultures times two and lactic acid level were not completed and that the Zosyn was not started. E#13 agreed the 3/5/18 7:15 AM orders for Dextrose 50 and 12 units of regular insulin were not followed.

3. An interview was conducted with the Director of Quality Management (E#3) throughout 3/12/19 to 3/15/19. E#3 had reviewed Pt #1's record and stated, "No, the orders (blood cultures, lactic acid level, Zosyn, Dextrose 50, and regular insulin) were not done. I don't know why some things were done and some weren't."

Based on document review and interview, it was determined in 1 of 4 patient (Pt #4) records reviewed for blood/blood product transfusions, the Hospital failed to ensure the blood product was administered as ordered. This has the potential to affect all patients who receive blood products at the Hospital.

Findings include:

1. Pt #4 Admission date: 3/10/19
Diagnoses: Ovarian Malignant Neoplasm and Hyponatremia (low blood sodium level). Pt #4's record was reviewed on 03/14/19 at approximately 2:00 PM.
a. On 3/11/19, there was a physician order for "25 g (grams) Albumin X (times) 2 doses". The Albumin Administration Record indicated 2 units of 12.5 grams albumin each were administered, for a total of 25 grams. The record lacked documentation of the second 25 gram Albumin dose.
b. On 3/12/19, there was a physician order for "2 x 25 g Albumin". The Albumin Administration Record indicated 2 units of 12.5 grams albumin each were administered, for a total of 25 grams. The record lacked documentation of the second 25 gram Albumin dose.

2. An interview with the Medical Surgical Director (E #18) was conducted on 03/15/19 at approximately 12:00 PM. E #18 reviewed Pt #4's record and stated "Our Albumin is all the same dose. It is 12.5 grams per unit." E #18 stated Pt #4 "did not receive the Albumin as ordered."

Based on record review and staff interview, it was determined in 4 of 4 patients' (Pt #1, Pt #2, Pt #3, and Pt #14) records reviewed for physician orders, the Hospital failed to ensure verbal and telephone orders were obtained and authenticated, in accordance with the Hospital's policy. This has the potential to affect all inpatients and outpatients serviced by the Hospital.

Findings include:

1. On 3/14/19 at approximately 3:00 PM the policy titled "Physician Orders" (reviewed by the Hospital on 11/2018) was reviewed. On page 1, the policy stated "Verbal orders must be signed before the physician/allied health professional leaves the area. Telephone orders must be signed within 48 hours."

2. Pt #1 Admission date: 3/4/18 Expired: 3/5/18.
Diagnosis: Abdominal Pain. Pt #1's record was reviewed on 3/12/19 to 3/13/19. Between 3/5/18 at 4:30 AM and 3/5/18 at 8:45 AM, there were one out of one verbal order and six out of nine telephone orders, which had not been signed as of 3/13/19, greater than one year later.

3. Pt #2 Admission date: 4/1/18 Expired: 4/2/18.
Diagnoses: Left Humeral Head Fracture and Left Femoral Head Fracture. Pt #2's record was reviewed on 3/13/19 at approximately 11:20 AM. On 3/31/18, there were twelve Emergency Department verbal orders, which were not authenticated by the physician until 4/6/18, six days later.

4. Pt #3 Admission date: 11/8/18 Expired: 11/10/18.
Diagnoses: Altered Mental Status, Hypoxemia, and Pneumonia. Pt #3's record was reviewed on 3/13/19 at approximately 12:30 PM.
a. On 11/8/18, there were twenty-one Emergency Department verbal orders, which were not authenticated by the physician until 11/19/18, eleven days later.
b. On 11/8/18, there were three telephone orders, which were signed between eight and seventeen days later.
c. On 11/9/18, there were five telephone orders, which were signed seven days later.
d. On 11/10/18, there were two telephone orders, which were signed fifteen days later.

5. Pt #14 Admission date: 3/1/19
Diagnoses: Hypokalemia and Fall. Pt #14's record was reviewed on 03/14/19 at approximately 3:30 PM.
On 3/8/19, there were two verbal orders and three telephone orders, which had not been signed by the physician as of 3/14/19.

6. In an interview with the Director of Obstetrics (E# 13) on 3/14/19 at approximately 3:45 PM, E#13 stated, "The orders for Pt #14 still have not been signed by the physician...I just looked again".

7. An interview was conducted with the Director of Obstetrics (E#13) on 3/14/19, during the review of Pt #1, Pt #2, and Pt #3's records. E#13 verbally agreed the verbal and telephone orders had not been signed in accordance with the Hospital's policy and they should have been. E#13 stated, "This is an ongoing struggle to get these (verbal and telephone orders) signed."

Based on record review and staff interview, it was determined in 3 of 3 patients' (Pt #1, Pt #2, and Pt #3) records reviewed for standing orders, the Hospital failed to ensure standing orders were initiated and authenticated, in accordance with its' policy. This has the potential to affect all inpatients and outpatients serviced by the Hospital.

Findings include:

1. On 3/14/19 at approximately 3:00 PM the policy titled "Physician Orders" (reviewed by the Hospital on 11/2018) was reviewed. On page 2, the policy stated, "3. Standing orders may be used and signed by the physician within 24 hours. Each time a standing order is used, it must be written on the Physician order sheet..."

2. Pt #1 Admission date: 3/4/19 Expired: 3/5/19.
Diagnosis: Abdominal Pain. Pt #1's record was reviewed on 3/12/19 to 3/13/19. On 3/5/19 at 2:00 AM, there was a "Per ICU (intensive care unit) Protocol" order for an MRSA (Methicillin Resistant Staphylococcus Aureus) anterior nasal swab. There was an undated, unsigned "Respiratory Therapy... Patients on a ventilator" standing order" in Pt #1's record. As of 3/13/19, neither had been signed by the physician.

3. Pt #2 Admission date: 4/1/18 Expired: 4/2/18.
Diagnoses: Left Humeral Head Fracture and Left Femoral Head Fracture. Pt #2's record was reviewed on 3/13/19 at approximately 11:20 AM. The following are examples of standing order deficiencies that were identified:
a. On 4/1/18, an "O.R. (Operating Room) Standing Orders", lacked the date and time of the order. The physician signature lacked the date and time it was authenticated.
b. On 4/2/18, a "Physician Orders... Pre-op (operative) Hip Pinning" standing order, lacked the date and time of the order and lacked authentication by the physician.
c. On 4/2/18, a "Physician's Orders- Surgical Admission" standing order set lacked the date and time of the order and lacked authentication by the physician.
d. On 4/2/18 at 8:40 AM, there was a "Anesthesia Post-Operative Orders" standing order that lacked the date and time it was authenticated by the physician. Pt #2 expired during the surgical procedure.

4. Pt #3 Admission date: 11/8/18 Expired: 11/10/18.
Diagnoses: Altered Mental Status, Hypoxemia. and Pneumonia. Pt #3's record was reviewed on 3/13/19 at approximately 12:30 PM.
a. On 11/8/18, there was an undated, untimed "Physician Orders- Telemetry" standing order that had not been authenticated by the physician as of 3/14/19.
b. A "Physician Orders- Admission" standing order was signed by the physician; however, lacked the date and time of the order.

5. An interview was conducted with the Director of Obstetrics (E#13) on 3/14/19, during the review of Pt #1, Pt #2, and Pt #3's records. E#13 verbally agreed the standing orders lacked one or more of the following: date, time, and/or authentication. E#13 stated, "We are really having a hard time getting our standing orders completed."

Based on observation, document review and interview, it was determined for 1 of 3 offsite locations (offsite #1), the Hospital failed to ensure supplies were not expired. This has the potential to affect all patients who receive care in the rehabilitation facility, with an average daily census of 100 -150 patients.

Findings include:

1. The Hospital policy titled "Medication, Biologics and Supplies Outdates (revised by the Hospital effective 8/15)", The policy required "...Policy: all...biological's and supplies to be used within the Manufacturers' expiration date... Process: A... Biologics and medical supplies will be checked monthly for outdates (expired dates). These will be disposed of..."

2. A tour of offsite #1 was conducted on 3/13/19 between 12:30 PM and 1:30 PM with the Director of Rehab Facilities(E #14). In a cabinet available for patient use were 5 bottles of 0.9 % Sodium Chloride for irrigation -500 milliliters (mls) with an expiration date of 2017.

3. During the tour with E#14, it was verbally confirmed the Sodium Chloride solution was outdated and should have been removed.

Based on observation, document review, and interview, it was determined the Hospital failed to ensure dietary staff followed manufacturer's guidelines for final rinse temperature on the dishwashing machine. This has the potential to affect all patients, staff, and visitors receiving dietary services in the Hospital.

Findings include:

1. During an observational tour of the Dietary Department conducted on 3/12/19 at approximately 3;00 PM, a poster near the dishwashing machine stated that the final rinse will be between 180 to 195 degrees.

2. The policy titled "Dishwashing Policy-High and Low Temp Warewash Instructional Poster" reviewed on 3/12/19 stated, "The poster is what we use to train our employees responsible for operating the Dish Machine. This poster is also located near the Dish Machine for reference."

3. On 3/12/19 at approximately 3:00 PM, the dishwashing/warewashing machine temperature logs dated 2/26/19-3/12/19 were reviewed. The temperature logs required that the final rinse temperature be checked 3 times per day (breakfast, lunch, and dinner). The temperature logs stated that twenty four of forty one final rinse temperature checks were below the manufacturer recommended final rinse temperature of 180-195 degrees Fahrenheit, with no documentation of action taken.

4. An email, dated 3/14/19, from an EcoLab representative to the Dietary General Manager (E#12) stated, "If using heat (i.e. hot rinse water in a high temperature warewasher), the surface temperature of the item must reach 160 degrees Fahrenheit, according to the 2017 FDA Model Food Code, Section 4-703.11. In order to achieve a 160 degree Fahrenheit surface temperature, a rinse water temperature of 180 degrees Fahrenheit is recommended."

5. During an interview with Dietary General Manager (E#12) on 3/14/19 at approximately 4:00 PM, E#12 confirmed the above findings and stated, "The manufacturer's guidelines do state final rinse should be between 180 to 195 degrees Fahrenheit and we should also be using the Ecolab temperature strips 3 times a day on Monday through Friday and twice per day on the weekend."

Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of the Recertification Survey conducted on March 12-14, 2019, the facility failed to provide and maintain a safe environment for patients, staff and visitors.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were cited. Also see A710.

Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of the Recertification Survey conducted on March 12-14, 2019, the facility failed to comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with the K-Tags.

Based on observation, document review, and interview, it was determined the Hospital failed to ensure the Hospital's preventive maintenance and equipment safety checks/monitoring processes were followed. This has the potential to affect all patients, staff, and visitors.

Findings include:

1. During a tour of the Obstetrics (OB), Medical Surgical (3rd) floor on 3/12/19 between 11:00 AM to 2:00 PM, the following equipment lacked a preventative maintenance label:
a) OB- nursery 1 infant warmer
b) OB- 2 breast pumps
c) OB- cesarean section room- 1 electrosurgical unit
d) OB-1 epidural pump

2. The manufacturers guidelines were reviewed on 3/15/19 at approximately 9:45 AM. The guidelines included:
a) nursery infant warmer- titled "Preventative Maintenance"required "...4.2 Maintenance Operational Checkout, before each use, the Resuscitaire Radiant Warmer should be checked for proper operation...".
b) breast pump- titled "Service Manual"...required "...5. Maintenance...recommended be inspected at least once every year..."
c) electrosurgical unit- titled "Testing the Generator"...required "...Use the generator only if it has completed the self-test...Confirming Outputs...confirming outputs...every six months..."
d) epidural pump- titled "Operational Checklist and Performance Acceptance Test"... required should be carried out before any service work is performed. If the device fails any test....it must be corrected prior to putting in service..."

3. During an interview with the Biomedical Engineer (E#17) on 3/14/19, at approximately 11:00 AM and 3/15/19 at approximately 10:00 AM, E#17 stated "The manufacturers guidelines are used for each equipment to determine when preventative maintenance and safety checks are done." E#17 verbally confirmed the above items haven't had preventative maintenance done prior to 3/14/19.

4. During tours on 3/13/19 between 12:30 PM and 1:30 PM of offsite #1, offsite #2, and offsite #3, with Director of offsite #1 (E #14), the Supervisor of offsite #2 (E #15), and the Director of the Wound and Hyperbaric Unit offsite #3 (E#16), the following equipment lacked a preventative maintenance label:

a) the balance manger, located at offsite #1
b) the Ultra Violet (UV) light located at offsite #2
c) the Cast cutter with vacuum located at offsite #3

The following Automated External Defibrillators (AED) that were available for emergency use lacked documentation that a daily equipment check was performed:

a) 1 on first floor at offsite #1
b) 1 at offsite #2
c) 1 at offsite #3

5. The manufacturers guidelines were reviewed on 3/15/19 at approximately 9:45 AM. The guidelines included:
a) balance manager- titled "General Maintenance"required...Annually- Inspect..."
b) UV light-no manufacturer guidelines
c) Cast cutter- titled "Autopsy Saw Owner's Manual and Operating Instructions" required..."A) Grounding continuity should be checked periodically...maintenance of a sharp blade is necessary..."

6. The manufacturers guideline for the AED were reviewed on 3/15/19 at approximately 8:30 AM. The guidelines required "...Maintaining and Troubleshooting...Maintaining the AED plus...inspect frequently, check for the green check...showing that the AED Plus is ready to use..."

7. During an interview with (E#17) on 3/14/19 at approximately 11:00 AM and on 3/15/19 at approximately 10:00 AM, E#17 stated "The manufacturers guidelines are used for each equipment to determine when preventative maintenance and safety checks are done." E#17 verbally confirmed the above items haven't had preventative maintenance done prior to the survey but are now added to the list.

8. An interview with E #14 , E#15, and E#16 was conducted during the tour on 3/13/19 at approximately 1:30 PM. E #14, E#15, and E#16 all stated that they were not aware the AED needed to have safety checks done.

A. Based on observation, document review, and interview, the hospital failed to ensure equipment was thoroughly disinfected in order to prevent/control infections and communicable diseases. This has the potential to affect all patients, staff, and visitors.

Findings include:

1. On 3/12/19 at approximately 2:00 PM, a tour was conducted of the 3rd floor Medical- Surgical unit with the Director of Medical Surgical unit (E#18). During the tour of the ice machine rooms, the "Ice Cart/Scoop Disinfectant Record" was requested and reviewed and the following deficiencies were identified:

a) For 2 South- November 2018- ice cart lacked disinfectant cleaning for the month; December 2018- ice cart lacked 2 of 2 disinfectant cleanings for the month and 6 out of 28 days the ice scoop lacked cleaning with soap and water; February 2019- the ice cart lacked disinfectant cleaning for the month

b) For 3 South- October 2018- ice cart lacked 3 of 4 disinfectant cleanings for the month; February 2019- ice cart lacked 2 of 4 disinfectant cleanings for month and 18 out of 28 days the ice scoop lacked cleaning with soap and water

2. The policy titled "Ice Cart Cleaning Procedure (reviewed by the Hospital on 3/2018)" was reviewed on 3/13/19 at approximately 1:00 PM. The policy required, "Process: Ice Carts A. Ice carts will be emptied, cleaned and disinfected with approved disinfectant on a weekly basis. (Friday, C shift) B. Ice scoops will be washed daily with hot soapy water. (AC shift) C. Document on weekly and daily logs..."

3. During an interview with Director of the Medical Surgical Unit (E#18) on 3/14/19 at approximately 1:15 PM, E#18 verbally confirmed the above mentioned lack of documentation for the cleaning and disinfectant of the ice cart/scoop.




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B. Based on observation, document review, and interview, it was determined the Hospital failed to ensure hand hygiene policy/procedures were followed to prevent the potential of cross contamination. This has the potential to affect all staff, visitors, and patients serviced by the Hospital.

Findings include:

1. An observational tour of the Medical Surgical Unit was conducted on 03/13/19 between 11:30 AM and 12:00 PM. Certified Nursing Aide (E #20) performed accu checks (checks of the blood sugar) on 3 patients. E #20 put on a pair of gloves, took the gloves off, and then put on another pair of gloves without performing hand hygiene, and proceeded to the next patient. The routine was repeated between each patient.

2. The Hospital policy titled, "Hand Hygiene" (reviewed by the Hospital on 12/2018) was reviewed on 3/14/19 at approximately 2:00 PM. The policy stated, "Using an alcohol-based hand sanitizer is appropriate for decontaminating the hands before direct patient contact; before putting on gloves; ... after contact with the patient; ... after removing gloves;..."

3. An interview was conducted with the Director of the Medical Surgical Unit (E #18 ) on 03/13/19 at approximately 12:00 PM. E #18 stated that E #20 did not perform appropriate hand hygiene and should have.

A. Based on document review and interview, it was determined for 5 of 5 Physicians (Medical Doctor- MD #5, MD #6, MD #7, MD #8, and MD #9), who perform moderate sedation, the Hospital failed to ensure physicians were granted privileges and training/competency for moderate sedation, in accordance with the Hospital's policy. This has the potential to affect all patients who require moderate sedation services.

Findings include:

1. The Hospital policy titled "Moderate Sedation" (last reviewed by the Hospital on 7/2018) was reviewed on 3/14/19 at approximately 4:00 PM. The policy stated, "Process:... The LIP (licensed independent practitioner) administering moderate sedation must have privileges for clinical administration of this category of drugs, with these individuals at a minimum receiving competency-based education, training and experience... including ACLS (Advanced Cardiac Life Support) certification... Competency of LIPs and registered nurses who administer moderate sedation shall be assessed, demonstrated and documented annually."

2. The physician credential files were reviewed on 3/14/19 at approximately 12:20 PM with the Medial Staff Specialist (E#9). MD #5, MD #6, MD #7, MD #8, and MD #9 whom provide moderate sedation services lacked the following:
a. MD#5 (Emergency Room) with an reappointment date of 1/4/18, lacked moderate sedation training/competency.
b. MD#6 (Emergency Room) with an reappointment date of 6/21/17, lacked moderate sedation raining/competency.
c. MD#7 (Gastroenterology) with an reappointment date of 6/5/18, lacked moderate sedation privileges.
d. MD#8 (Gastroenterology) with an initial appointment date of 7/19/17, lacked moderate sedation privileges and moderate sedation training/competency.
e. MD#9 (Gastroenterology) with an reappointment date of 6/7/18, lacked moderate sedation privileges, moderate sedation training/competency.

3. An interview was conducted with E#9 during the credential file review. E#9 stated, "I've checked with (E#8- Director of Education) and the physicians do not all have moderate sedation training and they should have. I didn't realize they (MD #7, MD #8, and MD #9) didn't have privileges (moderate sedation) and they should have."


B. Based on document review and interview, it was determined for 1 of 5 Registered Nurses (RN-E#21), whom perform moderate sedation, the Hospital failed to ensure moderate sedation training was performed, in accordance with its policy. This has the potential to affect all patients who receive moderate sedation.

1. The Hospital policy titled "Moderate Sedation" (last reviewed by the Hospital on 7/2018) was reviewed on 3/14/19 at approximately 4:00 PM. The policy stated, "Process:... shall be monitored by an RN trained in... and has satisfactorily completed the moderate sedation medication education program... Competency of LIPs (Licensed independent practitioners) and registered nurses who administer moderate sedation shall be assessed, demonstrated and documented annually."

2. The Pain Clinic RN (E#21's) personnel file was reviewed for moderate sedation training/competency on 3/14/19 at approximately 2:30 PM with the Director of Human Resources (E#22). E#21 was hired by the Hospital on 6/30/93 and performs moderate sedation in the Pain Clinic. E#21's file lacked moderate sedation training/competency.

3. An interview was conducted with E#22, during the personnel file review. E#22 verbally agreed E#21 does actively perform moderate sedation and should have current moderate sedation training/competency.

Based on document review and interview, it was determined for 9 of 14 Physicians (Medical Doctor- MD#1, MD#2, MD#3, MD#5, MD#6, MD#8, MD#9, MD#12, and MD#13) and 5 of 5 midlevel providers (Certified Registered Nurse Anesthetist- CRNA#1, CRNA#2, Physician Assistant- PA#1, Midwife #1, and Midwife #2), the Hospital failed to ensure physicians and midlevel providers completed initial and/or ongoing, annual Emergency Preparedness (EP) training. This has the potential to affect all physicians and midlevel providers who provide services at the Hospital.

Findings include:

1. The Physician and midlevel provider files were reviewed on 3/14/19 at approximately 12:20 PM with the Medical Staff Specialist (E#9).
a. Midwife #1 was initially appointed to the Medical Staff on 10/2/18. There was no documentation of initial EP training.
b. The following physicians and midlevel providers were reappointed to the Medical Staff and/or Allied Health Staff between 6/21/17 and 3/5/19: MD#1, MD#2, MD#3, MD#5, MD#6, MD#8, MD#9, MD#12, MD#13, CRNA#1, CRNA#2, PA#1, and Midwife #2. There was no documentation of ongoing annual EP training.

2. An interview was conducted with E#9 during the file review. E#9 verbally agreed the files lacked initial and/or ongoing annual EP training, "I will have to check on this."

3. An interview was conducted with the Director of Education (E#8) on 3/15/19 at approximately 8:40 AM. E#8 stated, "I send out packets annually, in August (to all physicians and midlevel providers), but they (packets) don't get sent back (verification that the information was read and/or received)."