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Based on record review and interview the hospital failed to set priorities for high-risk, high volume and problem-prone areas as evidenced by failing to monitor the hospital process and implement corrective action for delinquent medical records resulting in a 42% (Per cent) delinquency rate for the first quarter of 2012, and a 39% delinquency rate for the second quarter of 2012. The 1st Quarter of 2012 had 982 delinquent records out of 2340 discharged records. The 2nd Quarter had 856 delinquent records out of 2201 discharged records.
Findings:

On 07/24/12 at 3:00 p.m. an observation of the medical record department was conducted with S7 HIM (Health Information Management) Director and S1 Performance Improvement Officer. A separate room was observed for delinquent records with multiple shelves containing multiple delinquent records. S1 Performance Improvement Officer stated if the delinquency rate was less than 50% they were in compliance. S7 was requested to provide a list of the records that were delinquent over 30 days.

Review of the Delinquent Medical Records report provided by S7 HIM Director revealed the delinquency rate for January 2012 was 42%, February 2012 was 37%, March 2012 was 47%, April 2012 was 34%, May 2012 was 48%, and June 2012 was 35%. The delinquent medical record rate for the 1st Quarter of 2012 was 42% and the 2nd Quarter was 39%. Further review of the report revealed the 1st Quarter of 2012 had 982 delinquent records out of 2340 discharged records. The 2nd Quarter had 856 delinquent records out of 2201 discharged records.

On 07/26/12 at 10:45 a.m. in a face-to-face interview, S7 HIM Director was asked to provide a list of delinquent records for over 60 days and over 90 days. S7 stated she could not tell how many records were 30, 60, or 90 days delinquent. S7 stated the software resets the delinquent date to 0 every time the record is touched by the physician. S7 stated the system did not track delinquencies remaining after some corrections were made. S7 stated, "That's why we do it manually." S7 stated she relied on the weekly letters to the physicians to collect delinquent statistics. S7 verified she was unable to capture accurate data regarding delinquent medical records. S7 confirmed the over 60 day delinquent records were not captured on the monthly "Delinquent Physicians" reports. S7 stated she was unable to print a report of delinquent records that were completed. S7 confirmed the was responsible for forwarding physicians with medical record delinquent records to the Medical Staff for action, and stated the only physician she had referred to the Medical Director was Physician S17. S7 confirmed that the Medical Staff By-Laws were not followed for physicians that had delinquent records over 60 days.

Review of the "First Quarter 2012 Performance Improvement Evaluation" report revealed the indicators monitored by Medical Records were Delinquent Chart Rate, History and Physical not done in 24 hours, Operative Reports, and 24 hour dictated operative note.
Review of the Delinquent Chart Rate results revealed the following:
2010 rate = 41%
2011 rate = 41%
1st Quarter 2012 rate = 42%
Further review of the report revealed no documented evidence of a corrective action plan to address the delinquent chart rate.

On 07/26/12 at 1:30 p.m. S1 Performance Improvement Officer and S3 Director Quality Resources, were interviewed. S1 verified the above findings in the "First Quarter 2012 Performance Improvement Evaluation". S1 stated that Joint Commission requirements for medical records was that the delinquent medical record rate to be under 50%. S1 stated since their delinquent medical record rate was under 50%, they had not developed a corrective action plan or implemented any corrective actions to address the delinquent medical record rate of 41-42%. S1 stated she understood the problem with the computer in obtaining delinquent medical record data. S1 stated she knew S7 HIM Director was collecting the data by hand. S1 verified there was no system to accurately collect the delinquent medical record information and stated, "We have to find a better way."

Review of the hospital policy titled "Performance Improvement Plan", number 2.01, reviewed and revised 06/12, and provided by S1 Performance Improvement Officer as current, revealed in part the following:
Quality Improvement Goals
Goals/Steps
5. Select/develop data collection and data management systems with sufficient flexibility to adapt to ongoing internal and external content changes.
20. The hospital must set priorities that are focused on high-risk, high volume, or problem prone issues.

Based on record review, observation and staff interview, the hospital failed to meet the Condition of Participation (CoP) for Medical Records as evidenced by:

1) Failing to develop and implement a system to ensure that all medical records were promptly completed no later than 30 days after discharge as evidenced by having a 42% delinquency rate for the first quarter of 2012, and a 39% delinquency rate for the second quarter of 2012. (see findings at tag A0438).

2) Failing to have a system in place to accurately track delinquent medical records as evidenced by the hospital was unable to provide a list of delinquent medical records that included delinquent records over 30 days, over 60 days, and over 90 days. (see findings at tag A0438)

3) Failing to following Medical Staff Bylaws for suspension of physicians with delinquent records for 4 of 4 sampled physicians. (see findings at tag A0438)

4)Failing to properly store over 88,000 medical records to protect them from water damage. (see findings at tag A0438).

Based on observation, record review, Medical Staff Bylaws review, and interview, the hospital failed to ensure: 1) Each patient's medical record was promptly completed no later than 30 days after discharge by having a 42% delinquency rate for the first quarter of 2012, and a 39% delinquency rate for the second quarter of 2012, (2) there was a system in place to accurately track delinquent medical records, (3)Medical Staff Bylaws were followed for physicians with delinquent medical records for 4 of 4 sampled physicians (S17, S23, S24, S25);
4) Medical records were properly stored to protect them from water damage. Findings:

1) Each patient's medical record was promptly completed no later than 30 days after discharge as required by the medical staff rules and regulations:

On 07/24/12 at 3:00 p.m. an observation of the medical record department was conducted with S7 HIM (Health Information Management) Director and S1 Performance Improvement Officer. A separate room was observed for delinquent records with multiple shelves containing multiple delinquent records. S7 stated the HIM department sends the physician a notice of incomplete records weekly on Wednesday. S7 stated physicians were notified at 30 days of delinquent records by a letter indicating if delinquencies were not corrected within 24 hours they will be suspended. S7 stated if the physician was suspended 5 times in one year they were fined and would have to reapply for privileges. S1 Performance Improvement Officer stated if the delinquency rate was less than 50% they were in compliance. S7 was requested to provide a list of the records that were delinquent over 30 days.

Review of the "Delinquent Medical Records" report provided by S7 HIM Director revealed the delinquency rate for January 2012 was 42%, February 2012 was 37%, March 2012 was 47%, April 2012 was 34%, May 2012 was 48%, and June 2012 was 35%. The delinquent medical record rate for the 1st Quarter of 2012 was 42% and the 2nd Quarter was 39%. Further review of the report revealed the 1st Quarter of 2012 had 982 delinquent records out of 2340 discharged records. The 2nd Quarter had 856 delinquent records out of 2201 discharged records.

Review of the "Delinquent Physicians" monthly reports provided by S7 HIM Director revealed the following for Physician S17:
March 2012: 51 Total Deficiencies 30-52 days after discharge, Date Admitting privileges suspended: 03/29/12.
April 2012: 31 Total Deficiencies, 53 days after discharge.
May 2012: 61 Total Deficiencies, 60 days after discharge. The column titled, Hospital Privileges Lost, was blank.
Review of the "Delinquent Physicians" monthly reports from January 2012 to June 2012 revealed S17 was the only physician who had delinquent records 53 and 60 days after discharge.

On 07/25/12 at 2:30 p.m. in a face to face interview with the HIM Director S7, she confirmed that S17 had delinquent records over 60 day in the month of May 2012 and his admitting privileges were suspended. S7 stated she had prepared a letter notifying S17 that his hospital privileges were suspended and he would have to complete all delinquent records and reapply for medical staff privileges. S7 stated she had given the letter to S10 Medical Director and he said he would talk to Physician S17. S7 confirmed the letter was not sent to S17 and S17 did not lose his privileges. S7 stated it was a time-consuming process to suspend and reapply for hospital privileges. When asked what was being done to complete the delinquent records, she stated, "We work with the physicians". S7 stated the "Delinquent Physicians" monthly reports only indicated the new incomplete records for that month. S7 stated the delinquent records from the past months that were still delinquent were not included on the reports.

On 07/26/12 at 9:25 a.m., a face to face interview was conducted with S11 HIM staff, S7 HIM Director and S1 Performance Improvement Officer. S11 confirmed she was responsible for sending the weekly incomplete medical record notices to the physicians. S11 confirmed she had problems getting Physician S17 to complete his delinquent medical records. S11 stated Physicians S23, S24, and S25 were also problem physicians. S7 stated S10 Medical Director spoke to Physician S17 in May and S17 had been suspended from admitting, "for awhile". S7 confirmed she was aware of the regulation for medical records to be completed no later than 30 days after discharge. S7 stated, "We are trying to work with the physicians to get the records completed." The documentation of the weekly incomplete medical records for Physicians S17, S23, S24, and S25 was requested for review.

Review of the weekly incomplete medical records letters to the physicians revealed a letter to the physician indicating the discharge date, patient name, and reasons the record was incomplete. Review of the weekly incomplete medical records for Physicians S17, S23, S24, and S25 revealed the following:
Physician S17:
06/05/12 - 98 patient records incomplete over 30 days after discharge, and 55 records incomplete over 60 days after discharge.
06/13/12 - 6 patient records incomplete over 30 days after discharge, and 4 records incomplete over 60 days after discharge.
06/28/12 - 2 patient records incomplete over 30 days after discharge, and 14 records incomplete over 60 days after discharge.
07/05/12 - 40 patient records incomplete over 30 days after discharge, and 4 records incomplete over 60 days after discharge.
07/10/12 - 50 patient records incomplete over 30 days after discharge, and 6 records incomplete over 60 days after discharge.
07/18/12 - 54 patient records incomplete over 30 days after discharge, and 9 records incomplete over 60 days after discharge.
07/24/12 - 52 patient records incomplete over 30 days after discharge, and 15 records incomplete over 60 days after discharge.
There was no documented evidence of any suspension of privileges for Physician S17 in June or July 2012.


Physician S23:
06/05/12 - 90 patient records incomplete over 30 days after discharge, and 32 records incomplete over 60 days after discharge.
06/13/12 - 87 patient records incomplete over 30 days after discharge, and 36 records incomplete over 60 days after discharge.
06/28/12 - 8 patient records incomplete over 30 days after discharge, and 3 records incomplete over 60 days after discharge.
07/05/12 - 32 patient records incomplete over 30 days after discharge, and 3 records incomplete over 60 days after discharge.
07/10/12 - 40 patient records incomplete over 30 days after discharge, and 3 records incomplete over 60 days after discharge.
07/18/12 - 47 patient records incomplete over 30 days after discharge, and 5 records incomplete over 60 days after discharge.
07/24/12 - 39 patient records incomplete over 30 days after discharge, and 6 records incomplete over 60 days after discharge.
There was no documented evidence of any suspension of privileges for Physician S23 in June or July 2012.

Physician S24:
06/05/12 - 37 patient records incomplete over 30 days after discharge, and 10 records incomplete over 60 days after discharge.
06/13/12 - 31 patient records incomplete over 30 days after discharge, and 11 records incomplete over 60 days after discharge.
06/28/12 - 45 patient records incomplete over 30 days after discharge, and 9 records incomplete over 60 days after discharge.
07/05/12 - 56 patient records incomplete over 30 days after discharge, and 13 records incomplete over 60 days after discharge.
07/10/12 - 68 patient records incomplete over 30 days after discharge, and 18 records incomplete over 60 days after discharge.
07/18/12 - 59 patient records incomplete over 30 days after discharge, and 13 records incomplete over 60 days after discharge.
07/24/12 - 56 patient records incomplete over 30 days after discharge, and 19 records incomplete over 60 days after discharge.
There was no documented evidence of any suspension of privileges for Physician S24 in June or July 2012.

Physician S25:
06/05/12 - 28 patient records incomplete over 30 days after discharge, and 9 records incomplete over 60 days after discharge.
06/13/12 - 42 patient records incomplete over 30 days after discharge, and 9 records incomplete over 60 days after discharge (Review of the Delinquent Physicians Report dated June 2012, revealed Physician S25 was suspended from admitting privileges on 06/25/12).
06/28/12 - 40 patient records incomplete over 30 days after discharge, and 7 records incomplete over 60 days after discharge.
07/05/12 - 53 patient records incomplete over 30 days after discharge, and 17 records incomplete over 60 days after discharge.
07/10/12 - 57 patient records incomplete over 30 days after discharge, and 14 records incomplete over 60 days after discharge.
07/18/12 - 86 patient records incomplete over 30 days after discharge, and 20 records incomplete over 60 days after discharge.
07/24/12 - 138 patient records incomplete over 30 days after discharge, and 37 records incomplete over 60 days after discharge.
There was no documented evidence of any other action taken regarding the delinquent records for Physician S25.

(2) there was a system in place to accurately track delinquent medical records,

On 07/26/12 at 10:45 a.m. in a face-to-face interview, S7 HIM Director was asked to provide a list of delinquent records for over 60 days and over 90 days. S7 stated she could not tell how many records were 30, 60, or 90 days delinquent. S7 stated the software resets the delinquent date to 0 every time the record is touched by the physician. S7 stated the system did not track delinquencies remaining after some corrections were made. S7 stated, "That's why we do it manually." S7 stated she relied on the weekly letters to the physicians to collect delinquent statistics. S7 verified she was unable to capture accurate data regarding delinquent medical records. S7 confirmed the over 60 day delinquent records were not captured on the monthly "Delinquent Physicians" reports. S7 stated she was unable to print a report of delinquent records that were completed. S7 confirmed she was responsible for forwarding physicians with medical record delinquent records to the Medical Staff for action, and stated the only physician she had referred to the Medical Director was Physician S17. S7 confirmed that the Medical Staff By-Laws were not followed for physicians that had delinquent records over 60 days.

(3)Medical Staff Bylaws were followed for physicians with delinquent medical records for 4 of 4 sampled physicians (S17, S23, S24, S25);

On 07/26/12 at 1:15 p.m., a face-to-face interview with Physician S10, Medical Director was conducted. When asked what the Medical Staff process was to address physician's delinquent medical records, he stated first the physician got a faxed memo of his/her delinquent records. S10 stated the medical records department notified the physician by phone when the records were 30 days delinquent. S10 stated on day 31 medical records would notify the Chief of Staff if the delinquent records were not corrected. He stated they instituted a fine system (monetary fine) several years ago. S10 stated when it comes to suspending physicians, "There is some gray area". S10 stated he would have the CEO (Chief Executive Officer) involved for a suspension. After reviewing the Medical Staff Bylaws, he confirmed the bylaws for Medical Records as indicated below. When asked if the Medical Staff were following the Medical Records Bylaws, S10 stated, "Trying to. We've done different things." S10 stated Medical Records staff informed him of Physician S17's delinquent records and he talked to him. S10 also stated he thought he talked to Physician S23 about his delinquent medical records, but he wasn't sure. S10 stated that during Medical Executive Committee meetings he was given the number of delinquent medical records. S10 stated the majority of the delinquent records were from a few physicians, and Medical Records told him they had a plan to address the delinquent records. S10 confirmed the Medical Executive Committee had never suspended a physician for delinquent medical records. S10 stated he was not aware of any delinquent record problems with Physician S24 and Physician S25.

Review of the Medical Staff Bylaws approved by the Medical Staff and Board of Commissioners, reviewed and amended 11/09, and provided as current by S1 Performance Improvement Officer, revealed in part the following:
"Medical Records...18. Record of discharged patients shall be completed within thirty days (30) of the discharge date.
a. Weekly notices will be faxed to the physician every Wednesday listing their incomplete Medical Records.
b. 29 30 days = The HIM Department will notify the physician by phone that they have 1 day to complete delinquent records prior to suspension. At this point certain privileges will be suspended if records are not completed within this timeframe.
* The physician will still be responsible for unassigned call and performing emergency surgery related to unassigned call.
*Any pre-posted Surgeries/Special Procedures/Day Surgeries can be performed within seven (7) days of suspension notice. However, no other Surgeries/Special Procedures/Day Surgeries can be posted after suspension date.
c. 45-59 days = Privileges Lost Notice will be faxed every three days by the HIM Department and also sent by Certified mail from the Medical Executive Committee stating that the physician will lose all privileges and will have to reapply for medical staff membership. The date will be stated. The HIM Department will contact the Chief of Staff, who will then notify the physician that he will lose all privileges and will have to reapply for medical staff membership if the medical records are not completed within 15 days.
d. 60 days = Privileges Lost Notice will be sent by Certified mail by the Medical Executive Committee to notify the physician that privileges have been lost due to delinquent charts. The physician must reapply for medical staff membership. All benefits of Active Staff status are lost."

4) Medical records were not properly stored to protect them from water damage:

Observation of the medical record storage room on 07/24/12 at 3:00 p.m. with S7 HIM (Health Information Management) Director and S1 Performance Improvement Officer revealed completed patient records were stored on mounted rolling shelves. Observation of the rolling shelves revealed no means of protecting all sections of the shelves from water damage in the event the sprinkler system would activate. S7 confirmed the rolling shelves could not be closed entirely. S7 HIM stated patient records from June of 2008 to present were stored in the rolling shelves. Against the wall adjacent to the mounted rolling shelves the entire wall was observed to have open shelves with medical records stored on the shelves. S7 indicated the outpatient/observation/day surgery records were stored on these open shelves. Another area of open shelves was observed in the front of the room. Medical records were observed to be stored on these shelves. S7 indicated the records stored in this area were Emergency Department records. S7 stated the hospital medical records were a "hybrid" record with some of the record electronic and some still on paper. A sprinkler system was observed in the medical record storage room. S7 confirmed the medical record storage room was sprinklered. When asked how the medical records were protected from water damage, S7 stated, "We can't protect the records from water damage." S7 HIM Director provided documentation of the number of medical records stored in the medical record storage room, which revealed the following: Total inpatient medical records: 21,916. Total Emergency Department records: 46,887. Total Outpatient records: 19,402.


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An observation was conducted on 7/26/12 at 1:00 p.m. of an equipment storage room in the Intensive Care Unit (ICU). Open shelving was noted with patient's files containing Electrocardiogram (EKG) strips. Three shelves had approximately nine feet of files and one shelf had approximately six feet of files. A sprinkler system was located in the room.
In an interview on 7/26/12 at 1:00 p.m. with the Director of Quality Resources S3, she verified the equipment storage room in ICU contained files of patient EKG strips. She also stated the files were not covered to protect them from water. When asked how many files were in the room, S3 stated she did not know the exact number, but would estimate at least a thousand.

Based on observation and interview, the hospital failed to ensure all equipment was maintained in a manner to ensure an acceptable level of safety and/or quality as evidenced by failing to ensure the functionality of a nurse call button located on the handrails of the beds on the medical-surgical units. Findings:

Observations were made on the First South medical-surgical unit of the hospital on 07/23/12 between 10:40 a.m. and 11:30 a.m. with S1 Performance Improvement Officer and S12 RN, Unit Manager. A nurse call button was noted to be on the handrail of the beds in rooms 120 beds A and B, 125, 146, 149 bed A,. The button was noted to be non- functional as it failed to activate any type of nurse call system.

The RN Unit Manager (S12) and S1 Performance Improvement Officer were interviewed at the time of this observation. S12 confirmed that the nurse call button located on the handrails of the patient beds was not functioning when pressed. S12 indicated that they have a nurse call system which included a cord with a button and reported that patients are instructed to use this call system. When asked if it would be possible for a patient who may be confused or sedated to press the nurse call button on the handrail of the bed thinking they are calling for assistance without the nursing staffs' knowledge due to the call button not working, S12 and S1 indicated yes that would be possible. S12 stated most of the beds on the First South unit had this type of bed with the nurse call button located on the side rail.

On 07/23/12 at 3:40 p.m., the Director of Plant Operations (S13) was interviewed and verified the nurse call button in the bed rails on the medical-surgical units did not work. S13 stated the nurse call button on the bed rail did not work when the nurse call button on the cord was implemented. S13 stated they had to choose one system or the other.

On 07/25/12 at 1:20 p.m. S1 Performance Improvement Officer stated there was a total of 20 beds on First and Second South medical-surgical units with nurse call buttons in the bed rails that were not functional. S1 stated parts had been ordered to fix the nurse call button in the bed rails.

On 07/26/12 at 2:35 p.m., after the exit conference, S3RN, Director of Quality Resources indicated there were 2 beds with nurse call buttons in the bed rails that still did not work.

Based on observation, interviews and record reviews, the hospital failed to ensure consistent infection control practices were followed by all staff as evidenced by:
1) failing to ensure the staff appropriately used protective gowns and gloves for 2 of 3 sampled patients on contact isolation (#6 and #22).
2) failing to ensure hospital staff properly changed gloves and performed hand washing between cleaning patient rooms.
3) failing to ensure glucometers were cleaned between each patient use.
4) failure to ensure the surgical services maintained standards of practice during the decontamination process for all surgical instruments.
Findings:
1) Failing to implement contact isolation precautions
Patient #6
Review of Patient #6's medical record revealed he was a 72 year old male who had been admitted on 7/21/12. Further review of the skin assessment sheet revealed the patient had wounds on his left foot, right foot, and right arm.
A review was made of the Policy titled "Contact Precautions Green Tag" , Number 6.26, reviewed 1/9/06. The policy read in part:
3. Gowns are indicated if you anticipate that your clothes will have contact with the patient, environmental surfaces or items in the patient's room ...

In an observation on 7/24/12 at 2:15 p.m. in the intensive care unit, Patient #6 had a sign outside the room stating "Do Not Enter. Please check at Nurses Station" . The sign also had a green dot on it which indicated the patient was on contact isolation precautions.
In an observation on 7/24/12 at 2:15 p.m. in the intensive care unit, phlebotomist S4 entered Patient #6's room to draw blood. Before entering the room, she donned gloves but no gown. S4 approached the patient's bed and leaned against the right side while attempting to draw blood. S4 then walked around and leaned against the left side of the bed. Her shirt and arm came in contact with the patient #6's bed, sheets, and arm.
In an interview on 7/24/12 at 2:20 p.m. with phlebotomist S4, she stated she was aware that Patient #6 had a sign on their door indicating he was on contact isolation. She said she thought the green dot indicated she should have worn gloves, but thought a pink dot would have indicated she should have worn a gown. She stated she should have worn a gown while attempting to draw blood from patient #6.
In an interview on 7/24/12 at 2:26 p.m. with S6 Registered Nurse (RN), she stated Patient #6 was on contact isolation because he had open wounds. She also stated the Do Not Enter Sign with a green dot indicated the patient was on contact isolation.
Patient #22
On 07/23/12 at 10:40 a.m. the door to Patient #22's room was observed to have a sign which indicated, "Do Not Enter. Please check at Nurses Station". The sign also had a green dot on it which indicated the patient was on contact isolation precautions.
Review of the patient's medical record revealed the patient had a decubitus ulcer on the left heel with MRSA (Methicillin Resistant Staphylococcus Aureus).

On 07/23/12 at 2:30 p.m. an observation was made of RN S15 administering medication to Patient #22. S1Performance Improvement Officer and S12 RN, Manager of First South Unit remained in the hall outside the patient's room. The medication cart was also observed to be left in the hallway at the door of the patient's room. S15 was observed to put on an isolation gown and gloves prior to entering the patient's room. After taking the patient's vital signs, S15 was observed to remove her gloves and sanitize her hands. Gloves were then reapplied by S15. S15 was then observed to go to the medication cart, pick up the hand held scanner, and return to the patient's bed side. S15 removed the bed linens to expose the patient's arm, and scan the patient's armband. S15 was then observed to return the hand held scanner to the medication cart and open the medication drawer with her gloved hand. S15 did not remove her gloves and sanitize her hands after coming in contact with the patient. S1Performance Improvement Officer and S12 RN Manager confirmed that S15 had opened the medication drawer with her gloved hand.

Review of the hospital policy titled, "Contact Precautions", number 6.26, reviewed 01/09/2006, and provided by S1 Performance Improvement Officer as current, revealed in part the following: Purpose: Used in diseases that are transmitted through contact with infectious material. .....3. Gowns are indicated if you anticipate that your clothes will have contact with the patient, environmental surfaces or items in the patient's room or if the patient has: a)Incontinent b) Diarrhea c) Colostomy d) Ileostomy e)Wound Drainage not contained by a dressing. Place gown in trash hamper before leaving the room. 4. Wear gloves when entering the room. Remove and discard gloves and wash hands when leaving room. Do not let hands or clothing touch contaminated items when leaving room.

2) Failing to ensure hospital staff properly changed gloves and performed hand washing between cleaning patient rooms
In an observation on 7/24/12 at 1:50 p.m. on the Intensive Care Unit (ICU), the housekeeper S5 was observed cleaning patient rooms and emptying trash. S5 entered three separate rooms without changing gloves or washing her hands. She walked into the nurse's station and removed the glove from her right hand, picked up the phone and dialed a number. When she placed the phone back on the base, S5 placed the dirty glove back on her right hand. She then entered another patient room and emptied the trash can. S5 then exited the ICU without removing her gloves or washing her hands. The above mentioned observations were verified on 7/24/12 at 2:00 p.m. by S3 RN.
Review of the hospital policy titled, "Hand-Hygeine During Routine Patient Care and During Care of Patients on Isolation Precautions", number 6.10, reviewed 03/31/2010, and provided as current policy by S1 Performance Improvement Officer, revealed in part the following: ..... C. Handwashing Indications: ....10. Decontaminate hands after removing gloves...... D. Other Aspects of Hand Hygeine:...... 5. Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient, and do not wash gloves between uses with different patients.


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3) Failing to ensure Glucometer machines were cleaned after each patient use

On 07/23/12 at 10:40 a.m. observations were made on First South, medical-surgical unit. 6 patient rooms were observed to have a sign on the door which indicated, "Do Not Enter. Please check at Nurses Station". The sign also had a green dot on it which indicated the patient was on contact isolation precautions. S12 RN Unit Manager of First South unit was present and verified they had 6 patients on isolation. S12 stated there were various triggers for isolation and verified all the patients on isolation at this time were on contact isolation.
On 07/23/12 at 10:40 a.m. the door to Patient #22's room was observed to have a sign which indicated, "Do Not Enter. Please check at Nurses Station". The sign also had a green dot on it which indicated the patient was on contact isolation precautions.
Review of the medical record for Patient #22 revealed the patient had a decubitus ulcer on the left heel with MRSA (Methicillin Resistant Staphylococcus Aureus). The record also revealed the patient was ordered finger stick blood sugar (Glucometer checks) checks before meals and at bedtime.

On 07/23/12 at 11:20 a.m. S12 RN Manager of First South Unit was interviewed and confirmed the glucometers were used for multiple patients and they were brought in to the patient's room to perform the test. When asked what the procedure was for cleaning the glucometer, S12 stated the nurse assigned to the medication room on the night shift, wiped the glucometer with a sani-wipe. S12 stated this was the only time the glucometer was cleaned, unless it was visibly soiled.
On 07/23/12 at 1:40 p.m., S16RN was interviewed and confirmed she was the charge nurse on the IMC (Intermediate Care Unit) unit. S16RN verified there were 2 patients on the unit that were ordered glucometer checks. When asked what the procedure was for cleaning the glucometers, she stated the glucometer was cleaned with Cavi Wipes when the quality control checks were done on the night shift. S16 verified in the current practice, the glucometer was only cleaned one time on the night shift (7 p.m. to 7 a.m.).
Review of the policy titled, "Capillary Blood Glucose Monitor", number 12.03, revised 04/12, and provided as current policy by S1 Performance Improvement Officer as current, revealed no documented evidence of any guidance on how to clean the glucometer.
On 07/23/12 at 2:00 p.m., S1 Performance Improvement Officer was interviewed and verified the policy, "Capillary Blood Glucose Monitor", did contain any directions for cleaning the glucometers. S1 stated she had reviewed the CDC (Centers for Disease Control) website and confirmed the glucometers were required to be cleaned between patients. S1 verified she was not aware of this requirement until today. S1 provided another policy, titled "Accu-Check Inform Blood Glucose Monitoring System", revised date of 07/31/11, no number, which revealed in part the following: ....11. The following procedure should be used to clean the Accu-Chek Inform meter: Do not clean the meter while performing a patient or control test. Wipe surfaces with a soft cloth slightly dampened (not wet) with warm soapy water. May also wipe surfaces with a soft cloth slightly dampened (not wet) with 70% isopropyl alcohol.....
On 07/24/12 at 10:20 a.m. during an observation on the Rehabilitation Unit, S14RN, Rehab Manager was interviewed. When asked what the process was for cleaning glucometers, she stated that starting yesterday, they were cleaning the glucometer with alcohol preps after each patient use. S14 stated before yesterday, they were cleaning the glucometer every 1-2 days, and not after each patient use.
Review of the CDC (Centers for Disease Control and Prevention) guidelines for "Infection Prevention during Blood Glucose Monitoring and Insulin Administration", printed 04/19/11 revealed in part the following: "Recommended practices for preventing bloodborne pathogen transmission during blood glucose monitoring and insulin administration in healthcare settings:....Blood Glucose Meters - If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared."
Review of the FDA, U.S. Food and Drug Administration website revealed the following:
Use of Fingerstick Devices on more than one person poses risk for transmitting bloodborne pathogens: Initial Communication: Update 11/29/2010, Original date issued: 08/26/2010. Recommendations and FDA actions - the FDA and the CDC recommend that health care professionals and patients take the following immediate precautions:
Whenever possible, use POC (point of care) blood testing devices, such as blood glucose meters and PT/INR anticoagulation meters, for one patient only. If dedicating POC blood testing devices to a single patient is not possible, the devices should be properly cleaned and disinfected after every use as described in the device labeling.
4) Failure to ensure the surgical services maintained standards of practice during the decontamination process for all surgical instruments:

Failure to have a written decontamination policy governing the practices used to clean and decontaminate all surgery instruments, failing to ensure the central supply staff filled the water to the designated water fill-line marked in the large blue container for the Ecolab Antiseptic-Zyme cleaner, failing to ensure the surgical instruments soaked in the Ecolab Antiseptic-Zyme cleaner for one to five (1 - 5) minutes as per the manufacturer's instructions, and failing to ensure the surgical instruments were rinsed with water after soaking in the Ecolab Antiseptic-Zyme cleaner as per the manufacturer's instructions.

Review of the policy titled, "Nursing Unit Sterile Sets/Instrument Policy", policy number 3.22, effective date of 7/75, last reviewed and revised date of 7/12, revealed there was no documented evidence in the "Decontamination and Cleaning of Instruments" section governing the practices to be used by staff to clean and decontaminate the surgical instruments used during surgery cases. There was no documentation of a "Decontamination" policy presented during the survey conducted from 07/23/12 through 07/26/12.

During observations of the decontamination process conducted on 07/24/12 from 11:50 a.m. through 12:15 p.m., S20Central Supply Tech (CST) denied knowledge of a policy governing the practice that is to be used to clean the surgical instruments used during the surgical procedures performed at the hospital. During this observation, S20 was observed spraying the instruments (basic bone surgical instruments, S22MD's Pin Box instruments, small basic bone set, and cath lab mayo stand tray into a tub filled with Ecolab Antiseptic-Zyme Multi Detergent) with a spray bottle labeled, "Ecolab Antiseptic-Zyme Multi Detergent" cleaner. S20 then placed these instruments into the steris system without rinsing them with water. At 12:04 p.m., S20Central Supply Tech was observed placing a medium metal bowl and two (2) surgical clamps into a large blue container with a bluish solution, "Ecolab Antiseptic-Zyme Multi Detergent". There was a blue line drawn around the top of the container labeled, "fill-line". Further observation revealed the water was one (1) inch below the fill-line. There was a metal bowl that had the top two (2) inches that was not covered by the cleaner/water in the container. There were four (4) handles of the two (2) clamps sticking out of the cleaner/water noted in the blue container. At this same time, the Central Supply Tech, S20 was observed removing the bowl from the container and placing it on a shelf in the steris without allowing the bowl to soak in the cleaner and without rinsing it with water. S20 grabbed a metal tray from the steris and placed the clamps in it. She (S20) put the tray on a shelf in the steris without allowing the clamps to soak in the cleaner and/or without rinsing the bowl and clamps with water. At 12:05 p.m., S20 verified the water in the blue container was one inch below the fill line. S20 indicated she did not fill the water to the fill line as per protocol. S20 confirmed the bowl was sticking out of the cleaner and was not covered by the cleaner in the container as per protocol. S20 verified the handles of the two clamps were sticking out of the cleaner and were not submerged completely in the cleaner as per protocol. The Central Supply Tech, S20 indicated the enzymatic cleaner does not have a soak time. S20Central Supply Tech further indicated the instruments do not have to soak in the enzymatic cleaner for a specified time. She (S20) indicated the instruments do not need to be rinsed off by water after the cleaner is sprayed on them. S20Central Supply Tech further indicated the instruments should be covered by the cleaner as per protocol. S20Central Supply Tech indicated she had been performing decontamination process for six (6) years.

During another observation of the decontamination process on 07/24/12 from 2:00 p.m. through 2:10 p.m., S20Central Supply Technician, S18OR (operating room) Director, S19RN (charge nurse), and S27ICN (infection control nurse) revealed S20 donned a hairnet and shoe covers that were located in a drawer outside of the decontamination area with a dirty blue container on top of the cart. At 2:01 p.m., S20 entered the decontamination area where she donned gown and face shield. From 2:01 p.m. through 2:08 p.m., the Central Supply Technician, S20 manually cleaned S22MD's plastic set. At 2:08 p.m., Central Supply Technician, S20 was observed degloving, degowning and removed her face shield. S20Central Supply Technician did not remove the dirty hairnet at this time. At this time, S20 used the hand sanitizer located on the wall, got a cavi-wipe from the container located on the dirty area and cleaned the dirty countertop area. S20Central Supply Technician indicated at this time that the countertop was a clean area. At 2:10 p.m., S18OR Director, S19RN (charge nurse), and S27ICN all indicated the Central Supply Technician, S20 was dirty and the countertop was not clean; It was dirty. S27ICN and S18OR Director both further indicated S20's hairnet is dirty; not clean. At 2:12 p.m., S18OR Director stated there is a dirty instrument container noted on top of the clean hairnets and shoe covers located inside the cart.

During another observation and interview on 07/25/12 from 9:40 a.m. to 10:25 a.m., S19RN (charge nurse) confirmed there was a dirty blue instument container noted on top of the hairnets and shoe cover storage area located outside the decontamination area. S19RN indicated all central supply technicians get their hairnets and shoe covers prior to entering the decontamination area. S19RN (charge nurse) further indicated the top of the cart is dirty and the storage area for the hairnets and shoe covers is dirty.

In another interview on 07/26/12 at 11:20 a.m., S27ICN indicated there are no spotters for the operating room and/or decontamination area for handwashing surveillance.














25059

Based on record reviews, observations, and staff interviews, the hospital failed to meet the Condition of Participation for Surgical Services as evidenced by:

1) Failure to ensure the surgical services maintained standards of practice during the decontamination process for all surgical instruments as evidenced by failing to have a written decontamination policy governing the practices used to clean and decontaminate all surgery instruments, failing to ensure the central supply staff filled the water to the designated water fill-line marked in the large blue container for the Ecolab Antiseptic-Zyme cleaner, failing to ensure the surgical instruments soaked in the Ecolab Antiseptic-Zyme cleaner for one to five (1 - 5) minutes as per the manufacturer's instructions, and failing to ensure the surgical instruments were rinsed with water after soaking in the Ecolab Antiseptic-Zyme cleaner as per the manufacturer's instructions. (See deficiency cited at A0951); and

2) Failure to ensure the services were well organized and provided in accordance with acceptable standards of practice as evidenced by failing to ensure the surgical procedures were provided in a safe manner as evidenced by:

a) having an increased surgical site wound infection rates from 0% for the months of January, February, March, and May, to a 0.6 % (1 infection out of 178 procedures performed) increase in April, and a 2.7 % (5 infections out of 188 procedures performed) increase in June, and

b) having 1 (R2) of 1 focused surgical site wound infection reported with Staphylococcus aureus (MRSA) for April of a total of 6 (R2, R3, R4, R5, R6, R7) focused random records reviewed for surgical site wound infections out of 178 surgical procedures performed. and two (R3, R5) out of four (R3, R5, R6, R7) focused surgical site wound infections with Staphylococcus aureus (MRSA) reported out of 188 surgical procedures performed for June 2012. (See deficiency cited at A0940).

Findings:

a)Review of the "Infection Prevention-2012" report revealed there were zero healthcare associated infections for surgical wounds reported for the months of January, February, March and May of 2012. Further review of the report revealed there was 1 (0.6%) healthcare associated infection for surgical site wound infection reported out of the 178 surgical procedures performed in April. There were 5 (2.7%) healthcare associated infections for surgical wounds reported out of the 188 surgical procedures performed in June.

b)Review of the "Nosocomial Report from discharge date of 04/01/12 thru 04/30/12 revealed S10MD had 1 (R2) surgical site infection for the month of April. Further review of the "Nosocomial Reports from discharge date of 06/01/12 thru 06/30/12 revealed there were a total of 5 (R3, R4, R5, R6, R7) surgical site infections reported for the month of June 2012. Of the 5 surgical site infections 4 were infected with Staphylococcus aureus (MRSA) S10MD had surgical site infections for 2 (R3, R5) of the 4 Staphylococcus aureus (MRSA) surgical site infections for the month of June.

R2:
Review of the "Operative Reports" for random patient #2 (R2) revealed the patient had a left total hip arthroplasty surgical procedure performed on 03/28/12 by S10MD and an irrigation and debridement of the left hip with cultures performed on 04/17/12 by S10MD.

Review of the left hip wound culture collected on 04/17/12 at 1:38 p.m. (1338) and resulted on 04/19/12 at 7:25 a.m. (0725) read in part, "...exhibits heteroresistance to oxacillin, penicillins (including penicillinase-resistant penicillins) and cephalosporins are not indicated...Staphylococcus aureus heavy growth..."-Methicillin-resistant Staphylococcus aureus (MRSA) for R2.
R3:
Review of the "Operative Reports" for random patient #3 (R3) revealed the patient had a left total hip arthroplasty surgical procedure performed on 06/04/12 by S10MD and an irrigation and debridement of the left hip with cultures performed on 06/27/12 by S10MD.

Review of the abscess culture for collected on 06/27/12 at 4:40 p.m. (1640) and resulted on 06/29/12 at 7:36 a.m. (0736) read in part, "...exhibits heteroresistance to oxacillin, penicillins (including penicillinase-resistant penicillins) and cephalosporins are not indicated...Staphylococcus aureus heavy growth..."-Methicillin-resistant Staphylococcus aureus (MRSA) for R3.
R5:
Review of the "Operative Reports" for random patient #5 (R5) revealed the patient had a left total hip arthroplasty surgical procedure performed on 06/01/12 by S10MD.

Review of the "Physician's Orders" dated/timed 06/12/12 at 11:00 a.m. (1100) read, "culture hip drainage".

Review of the left hip wound culture collected on 06/12/12 at 2:16 p.m. (1416) and resulted on 06/15/12 at 9:58 a.m. (0058) read in part, "...exhibits heteroresistance to oxacillin, penicillins (including penicillinase-resistant penicillins) and cephalosporins are not indicated...Staphylococcus aureus heavy growth..."-Methicillin-resistant Staphylococcus aureus (MRSA) for R5.
In an interview on 07/26/12 at 10:30 a.m., S27Infection Control Nurse (ICN) verified S10MD had a surgical site wound infection with Staphylococcus aureus (MRSA) (R2) for the month of April. S27ICN further verified S10MD had 2 (R3, R5) of 4 patients with surgical site wound infections with Staphylococcus aureus (MRSA) for the month of June. The ICN, S27 confirmed the healthcare associated surgical wound site infection rates increased from zero percent in January, February, March and May to a 0.6 % (1 of 178 procedures) in April and to a 2.7 % increase (5 of 188 procedures) in June of 2012.
During an interview conducted on 07/26/12 at 10:30 a.m., S26Chief Technologist verified R2, R3 and R5 lab cultures read, "exhibits heteroresistance to oxacillin, penicillins (including penicillinase-resistant penicillins) and cephalosporins are not indicated...Staphylococcus aureus heavy growth..." indicating the the organism was Methicillin-resistant Staphylococcus aureus (MRSA). S26 indicated the MRSA organism is not written on the lab culture report instead it is reported as "exhibits heteroresistance to oxacillin, penicillins (including penicillinase-resistant penicillins) and cephalosporins are not indicated...Staphylococcus aureus heavy growth..." which is Methicillin-resistant Staphylococcus aureus (MRSA).

Based on record reviews, observations, and staff interviews, the hospital failed to ensure the surgical services maintained standards of practice during the decontamination process for all surgical instruments as evidenced by failing to have a written decontamination policy governing the practices used to clean and decontaminate all surgery instruments, failing to ensure the central supply staff filled the water to the designated water fill-line marked in the large blue container for the Ecolab Antiseptic-Zyme cleaner, failing to ensure the surgical instruments soaked in the Ecolab Antiseptic-Zyme cleaner for one to five (1 - 5) minutes as per the manufacturer's instructions, and failing to ensure the surgical instruments were rinsed with water after soaking in the Ecolab Antiseptic-Zyme cleaner as per the manufacturer's instructions. Findings:

Review of the policy titled, "Nursing Unit Sterile Sets/Instrument Policy", policy number 3.22, effective date of 7/75, last reviewed and revised date of 7/12, revealed there was no documented evidence in the "Decontamination and Cleaning of Instruments" section governing the practices to be used by staff to clean and decontaminate the surgical instruments used during surgery cases. There was no documentation of a "Decontamination" policy presented during the survey conducted from 07/23/12 through 07/26/12.

During observations of the decontamination process conducted on 07/24/12 from 11:50 a.m. through 12:15 p.m., S20Central Supply Tech (CST) denied knowledge of a policy governing the practice that is to be used to clean the surgical instruments used during the surgical procedures performed at the hospital. During this observation, S20 was observed spraying the instruments (basic bone surgical instruments, S22MD's Pin Box instruments, small basic bone set, and cath lab mayo stand tray into a tub filled with Ecolab Antiseptic-Zyme Multi Detergent) with a spray bottle labeled, "Ecolab Antiseptic-Zyme Multi Detergent" cleaner. S20 then placed these instruments into the steris system without rinsing them with water. At 12:04 p.m., S20Central Supply Tech was observed placing a medium metal bowl and two (2) surgical clamps into a large blue container with a bluish solution, "Ecolab Antiseptic-Zyme Multi Detergent". There was a blue line drawn around the top of the container labeled, "fill-line". Further observation revealed the water was one (1) inch below the fill-line. There was a metal bowl that had the top two (2) inches that was not covered by the cleaner/water in the container. There were four (4) handles of the two (2) clamps sticking out of the cleaner/water noted in the blue container. At this same time, the Central Supply Tech, S20 was observed removing the bowl from the container and placing it on a shelf in the steris without allowing the bowl to soak in the cleaner and without rinsing it with water. S20 grabbed a metal tray from the steris and placed the clamps in it. She (S20) put the tray on a shelf in the steris without allowing the clamps to soak in the cleaner and/or without rinsing the bowl and clamps with water. At 12:05 p.m., S20 verified the water in the blue container was one inch below the fill line. S20 indicated she did not fill the water to the fill line as per protocol. S20 confirmed the bowl was sticking out of the cleaner and was not covered by the cleaner in the container as per protocol. S20 verified the handles of the two clamps were sticking out of the cleaner and were not submerged completely in the cleaner as per protocol. The Central Supply Tech, S20 indicated the enzymatic cleaner does not have a soak time. S20Central Supply Tech further indicated the instruments do not have to soak in the enzymatic cleaner for a specified time. She (S20) indicated the instruments do not need to be rinsed off by water after the cleaner is sprayed on them. S20Central Supply Tech further indicated the instruments should be covered by the cleaner as per protocol. S20Central Supply Tech indicated she had been performing decontamination process for six (6) years.

In an interview on 07/24/12 at 12:20 p.m., S18Operating Room (OR) Director denied knowledge of what the decontamination process was for manually cleaning and disinfecting the surgical instruments used by the physicians during the surgery cases performed at the hospital.

During an interview on 07/24/12 at 3:03 p.m., S19RN, Operating Room (OR) Charge Nurse denied knowledge of what the decontamination process was for cleaning and decontaminating all surgical instruments. The Charge Nurse, S19RN verified the "Nursing Unit Sterile Sets/Instrument Policy" failed to indicate what practices were to be used by staff to clean and decontaminate all surgical instruments used during the surgery cases.

Review of the manufacturer's instructions for the Ecolab Asepti-Zyme Multi Detergent revealed the Presoak and Manual Cleaning of the instruments process was to presoak the instruments as needed until the soil was dissolved and removed from the instruments. This process should take one to five minutes. Enzymes must engulf the organic matter before it can be dissolved. If the organic material is aged or difficult to remove, then an extended soak time may be necessary. (In severe instances, light mechanical cleaning with an instrument brush may be necessary.) Rinse items thoroughly, then proceed with normal decontamination process.