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Based on record review and interview, the facility failed to inform and obtain 3 (#s 1, 8, and 19) of 29 sampled patients of the patient rights, advance directives, and the grievance process. Findings include:

1. A review of patient #1's medical record, failed to show evidence the facility obtained advance directives for the patient. A review of the patient record showed, "Current Code Status, this patient does not have a recorded code status. Please follow your organizational policy for patient in this situation. Code Status History, this patient does not have a recorded code status. Please follow your organizational policy for patients in this situation."

2. A review of patient #8's medical record, failed to show evidence the facility obtained advance directives for the patient. A review of the patient record showed, "Current Code Status, this patient does not have a recorded code status. Please follow your organizational policy for patient in this situation. Code Status History, this patient does not have a recorded code status. Please follow your organizational policy for patients in this situation."

During an interview on 3/19/17 at 9:06 a.m., staff member A stated it was the expectation of staff and of the facility to obtain the advance directives of patients on admit. Staff member A stated if further explanation of advanced directives was needed by the patient, a referral would be sent to social services.

3. A review of patient #19's medical consent for treatment, showed no evidence the patient had been notified of the patients' rights, or the process for grievances.

During an interview on 3/8/17 at 3:50 p.m., staff member A said normally there would be an indication on the consent to treat form, signed by the patient, if the patient had been given this information.

A review of the facility's policy titled, Informed Consent, showed, "1. A general Consent for Hospital Care and Treatment is signed by any patients (or surrogate) receiving care at [facility name]. 2. Informed consent is necessary for a procedure or treatment that involves risks beyond that associated with routine care. a. Informed consent should be obtained in writing whenever possible so that such consent is clearly documented in the patient's EMR. b. A properly executed informed consent contains documentation of a patient's (or surrogate's) mutual understanding of, and agreement for, care, treatment, or services through written signature."

Based on observation and interview, the facility failed to transport soiled linen in an acceptable way to minimize the effects of direct and indirect transmission. The facility also failed to keep corridor doors to soiled laundry rooms closed. The deficiency could affect all patients, staff and visitors. Findings include:

During observations on 3/6/17 at 2:30 p.m. and 3/7/17 at 9:30 a.m., the soiled laundry room on the service wing was inspected. The door to the room was held open with a magnetic door hold-open-device. There was soiled laundry in bags in large wheeled containers.

During an interview on 3/8/17 at 1:25 p.m., staff member C stated he did not sit on the infection control committee. He did not know if there were any recent infections he should be aware of. He stated that the laundry was done offsite, and he did not monitor the contracted laundry service. He stated there was an initial agreement between the laundry service and the facility which the facility had written policies and procedures for handling linens and laundry. He stated the facility did not sort any bagged laundry, but only loaded the bagged laundry into large carts which were transported to the laundry service. He stated facility employees did not wear aprons when loading bags into the large carts, only single-use gloves were worn.

During observations on 3/9/17 starting at 7:45 a.m., staff member H obtained a blue laundry bag from the soiled laundry room, removed soiled bedding from a bed on the Swing unit, and prepped the resident for her shower. Staff member H stuffed the soiled linen into the laundry bag contaminating her gloves, clothing and the outside of the laundry bag. She then held the bag under her arm while transporting it to the soiled laundry room, further contaminating her clothing. She removed her gloves and washed her hands. She returned to the resident's room to transport the resident to the shower room.

During observations on 3/9/17 at 8:25 a.m., staff member D picked up soiled laundry throughout the facility, along with staff members C and E. Staff member D picked up soiled laundry at five different locations. Staff member D contaminated his gloves and clothing, and did not remove his gloves before touching the cart handle. He then went back into the soiled linen room, removed his gloves, and washed his hands for seven seconds. He then pushed the cart to the next location. During a second observation, he stopped to rearrange the soiled laundry in the bag to get it to fold properly before tossing it into the cart. The bags used to store laundry had a flap opening which made it more difficult to stuff laundry into them. When roughly handled, the flap would come open exposing laundry. Staff member D failed to wash his hands properly after handling contaminated laundry bags and failed to handle bags in such a way as to minimize agitation and prevent cross-transmission.

Based on record review, and interview, the facility failed to ensure informed consents for blood transfusions were properly executed for 2 (#s 7 and 8) of 29 sampled patients. Findings include:

1. A review of patient #7's medical record showed a Consent to Blood Transfusions were signed by the patient, but the section requiring the physician's signature was not signed, dated or timed.

2. A review of patient #8's medical record showed a Consent to Blood Transfusion was signed by the patient, but the section requiring the physician's signature was not signed, dated or timed.

During an interview on 3/9/17 at 9:06 a.m., staff member A stated it was the expectation of the staff and of the facility to obtain the appropriate signatures needed for the Consent to Blood Transfusion forms. Staff member A stated the facility changed their Consent to Blood Transfusion forms in December 2016 to include the section for the provider to sign their declaration that they had explained the procedure/operation and the potential risks associated with the procedure to the patient prior to the procedure.

A review of the facility's policy and procedure titled, Informed Consent, showed, "To ensure that the patient and/or his/her surrogate is provided appropriate information by the clinician who is performing the surgery or rendering services so as to obtain informed written consent."

Based on observation, interview, and record review, the facility failed to ensure medical record information was protected against loss or destruction. Finding include:

During an observation on 3/8/17 at 1:14 p.m., a white circular smoke detector was on the ceiling of the "West" shed. The inside parameter of the shed was lined with paper medical records on risers from the floor to several inches from the ceiling.

During an interview on 3/8/17 at 1:14 p.m., staff member K stated she was not sure if the batteries worked in the smoke detector in the "West" shed. She stated maintenance had mentioned a problem with the smoke detector but could not remember if they checked the batteries.

During an observation on 3/8/17 at 1:20 p.m., there was no smoke detector in the "East" shed. The "East" shed had paper medical records from the floor to several inches below the ceiling around the inside parameter of the building, and on shelves throughout the shed.

During an interview on 3/8/17 at 1:20 p.m., staff member K stated she did not see a smoke detector in the "East" shed. The staff member stated it would be important to have a functioning smoke detector to alert staff of a fire to prevent destruction of the medical records.

During an interview on 3/9/17 at 8:56 a.m., staff member L stated the "Old Building's" (also referred to as the "West" shed) smoke detector was wired to the fire panel inside the facility. He stated for several months the smoke detector had been "non-functional." He stated when the detector was on, it sent an alert signal to fire panel and the alarm sounded constantly. Staff member L stated a decision was made to disconnect the smoke detector in the "West" shed from the rest of the fire panel. Staff member L stated the "New Building" (Also referred to as the "East" shed) did not have a fire alarm system inside the building.

A review of the facility's policy and procedure titled, Health Record, Retention and Destruction, showed the following: "Off-site storage facilities are to be in secure locations that safeguard the Health Records from the following: Disasters such as fire, flood, earthquake, hurricane, wind, and explosions."

Based on record review, and interview, the facility failed to specify and delineate surgical privileges of the practitioners performing surgery and surgical procedures. This deficient practice had the potential to affect all residents who received surgical procedures from the identified practitioners, staff members I and J. Findings include:

1. During a review of staff member's I's General Surgery Core Privileges, the contract showed under the procedure section titled, Basic laparoendoscopic operative procedures, to include:
- Cholecystectomy;
- Herniorrhaphy (ventral or inguinal);
- Appendectomy;
- Colectomy.

There was a hand-written "x" by the cholecystectomy, appendectomy, and the colectomy. There was not an "x" by the herniorrhaphy (ventral or inguinal). Further review of the contract showed endoscopy-EGD, colonoscopy, arterial bypass, endarterectomy, and aneurysm repair were hand-written into the contract. The contract was unclear if the provider had privileges approved for the "x" out items or not. The hand-written documentation could not be determined to be approved at the time of the privileging or written into the contract later.

2. During a review of staff member J's General Surgery Core Privileges, the contract showed, "GI endoscopy/polypectomy/hemorrhage removal" was hand-written into the side of the contract. The hand-written documentation could not be determined to have been approved at the time of the privileging or written into the contract later.

During an interview on 3/7/17 at 1:35 p.m., staff member A stated the physician received the contract for General Surgery, Core Privileges, and reviewed the privileges. The provider would write in any additional surgical procedures they would like to be considered for privileges on the contract. The contract then went to Credentialing. After Credentialing approved the privileges, the contract was then sent to the Medical Executive Committee for Peer review and approval. Once the Medical Executive Committee approved the contract, the contract was sent to the President of the Medical Staff for approval. Staff member A stated the hand-written documentation and the "x" on the contracts did not clearly specify the privileges.

Based on interview and record review, the facility failed to implement its organ procurement policies when it did not report the imminent death of a patient to the organ procurement organization with which it held an agreement. This practice had the potential to affect the outcome of one potential donor's ability to donate. Findings include:

A review of resident #22's medical record showed no evidence the organ procurement organization, with which the hospital holds an agreement, was notified of the resident's imminent death.

During an interview on 3/8/17 at 3:50 p.m., staff member A said patient #22 had been on hospice and reporting the death to the organ procurement organization had been overlooked by the hospital staff and hospice staff. She said, "I think it was totally missed on this end."