HospitalInspections.org

Based on facility policies, review of documents, staff interview, and a tour of the hospital, the facility failed to ensure a sanitary environment to avoid sources of transmission of infections.

Findings included:

"OSHA/Blood Borne Pathogen Regulations Policy #138-030-060" stated in part "The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner."
In an article published by Spectrum Health in July, 2014 it was stated "The heavier corrugated cardboard shipping boxes might harbor vermin or insects and spread the pests to areas where the boxes are stored after delivery. Corrugated cardboard boxes are not appropriate as storage units in medical or clean supply rooms. These boxes are not appropriate because they are an excellent harbor for insects and pests."

Facility document entitled "Infection Control",
Policy Title: Management of Regulated Waste", states in part,
2. Linen: "Linen is to be handled with appropriate precautions.
a. Linen is to be handled as little as possible and with minimum agitation. Linen should be bagged and the bag closed at the location of use.
b. Dirty, wet linen will be placed in clear plastic bags, tied and placed in linen bags provided by the laundry service.
c. Housekeeping will transport the soiled linen to the holding room until it is released to the linen company for handling.
d. Clean and dirty linen will be kept separate."

A tour of the hospital was conducted the morning of 01/22/2018, accompanied by the Chief Executive Officer and the Director of Nursing. During the tour of the hospital the following was observed.

Food storage room observed X 2 large opened shipping boxes
1 package of wheat tortillas with a sell by date of 5-19-18.
X 5 Gallon food cans did not have expiration dates.
X 2 Gallon plastic containers of Miracle Whip with no expiration date.

Pharmacy: X1 shipping box.
Radiology: X2 shipping boxes, one observed on the floor behind the CT Scanner.

Rehab/Physical Therapy: Ceiling stain in the hallway by room 125.
Foams pads used for patient support were on the floor.

Dirty/Soiled linens were stored outdoors in a large opened container.

The housekeeper was available for inspection of the clean linen and dirty linen area. The surveyor was directed outdoors to the hospital's delivery area. Clear and red plastic bags containing soiled linen was observed in a large red open container (Poly Bulk Truck) with low cut sides. The container was unsecured and could be accessed by anyone that was outdoors.

The hospital's housekeeper staff #22 stated "the hospital's dirty/soiled linen picked up every Wednesday by the contracted linen services."

The above findings were confirmed on the morning of 01/22/2019 by the Chief Executive Officer and the Director of Nursing.

Based on review of facility documents, review of medical records and staff interview, the facility failed to ensure care was provided in accordance with the patient's needs.

Findings included:

Radiology Technologist Position Description stated in part, "Summary: Performs a full range of radiology tests ... Promotes and provides compassionate and quality patient care.
...Essential Duties and Responsibilities:
...Perform radiological exams on patients in a timely and professional manner.
...Accurately and promptly implements provider's orders."

Registered Nurse, Charge, Position Description stated in part, "Summary: Plan, organize, direct, provide and evaluate care needed to maintain safety and improve the health and wellbeing of patients through the implementation of the nursing process. Provides oversight for all nursing care processes provided by other members of the nursing staff. Serve as patient advocate and be actively involved in the care of the patient and support of family members. Communicate effectively for continuity of care among patients, families, ancillary personnel and hospital departments.
...Essential duties and responsibilities:
...Advocate for patient.
...Continually monitor to assure medical provider's orders for the patient's care are being carried out ..."

Review of the medical record for patient #25 revealed a nursing note dated 11/28/19 at 2:40 pm that stated in part, "Pt. [patient] up to bathroom with assistance ... Pt. went week [sic] and diaphoretic [severe sweating] upon getting up from toilet. This nurse answered assistance light in pt. room. Pt. unable to stand, diaphoretic, and unresponsive to voice. Pt. put in recliner ... Pt. unresponsive to sternal rub [painful rubbing in center of chest] initially. Pt. did open eyes, upon opening eyes, pt. eyes fixated to left. Pt. placed in bed from recliner without incident."

Nursing note dated 11/28/19 at 2:45 pm stated in part, "NP [nurse practitioner] in pt. room at bedside."

An order for a CT [computed tomography, series of x-rays to visualize internal injuries] of head without contrast STAT [immediately] was dated 11/28/18 at 2:54 pm that stated in part, "Reason for Procedure: SYNCOPE [fainting] Transport Method: bed."

This order was acknowledged by nursing staff on 11/28/18 at 7:11 pm. This order was not completed but was discontinued on 11/29/18 at 12:16 pm.

Nursing note dated 11/28/19 at 3:32 pm stated in part, "Pt. eyes are no longer fixated, pt. is conscious but not oriented, appears lethargic ..."

Nursing note dated 11/29/18 at 10:20 am stated in part, "Patient receiving physical therapy [PT] and went limp, diaphoretic, and non-responsive. PT staff called for assistance to nursing staff. Pt assisted back to bed. Pt returns to normal level of consciousness within 10 minutes. Patient placed on telemetry and fluids continue to run at this time."

Another order for a CT of head without contrast STAT was dated 11/29/18 at 12:06 pm that stated in part, "Reason for Procedure: Syncope, recent CVA [cerebrovascular accident/stroke], on Plavix [blood thinner] Transport Method: bed. Patient at Risk for Falls: Yes ..."

The CT results completed on 11/29/18 at 12:16 pm stated in part, "IMPRESSION: APPARENT ACUTE CEREBRAL HEMORRHAGE [bleeding in the brain] WITH BLEEDING INTO THE LATERAL VENTRICLES [cavities in the brain] ON BOTH SIDES ..." She was transferred to a nearby Intensive Care Unit on 11/29/18 at 2:00 pm.

The original STAT order dated 11/28/18 was not completed with no documentation to support why. The patient remained on the unit and had another syncopal episode the next day. Another STAT CT of the brain was ordered on 11/29/18, was completed and revealed patient #25 had bleeding in the brain and was transferred out.

In an interview with the CEO on the afternoon of 1/22/19, when asked the expectations for a STAT order to be carried out, she stated, "Immediately." When asked why the original order was not completed, she stated staff present that day stated the doctor told them to hold the order. There was no documentation regarding why the order had not been completed.