HospitalInspections.org

Based on hospital documents and staff interviews the hospital failed to maintain a list of all contracted services.

Findings:
1. On December 15, 2015 at 11:45 a.m. surveyors requested a list of all contracted services including the scope and nature of the services provided.

2. The Chief Executive Officer (CEO) provided a list of contracted services to surveyors. Not all contracted services were listed. Missing contracted services were: Organ Procurement Organization, Radiation Consultants, Radiation Monitoring, and Tele-Radiology.

3. The CEO verified that the list of contracted services was not completed.

Based on review of patient grievances, hospital policy and procedure review, and staff interview, the hospital failed to respond to all grievances in writing.

Findings:

1. On December 15, 2015 at 1:45 p.m. hospital administration was asked to provide documentation of all complaints and grievances for the previous six months. There were two (patient #26 & #27) complaints that were actually grievances. The two complaints were investigated and appropriate steps were taken on behalf of the patient. The hospital failed to provide the patient with written notice of its decision.

2. On December 15, 2015 at 1:45 p.m. the Risk Manager told surveyors that she was new to the position and didn't know that the two complaints (patient #26 & #27) were actual grievances. The Risk Manager told surveyors that the two complaints (patient #26 & #27) did not receive a letter.

3. Surveyors requested the hospital's complaint and grievance policy. Surveyors received and reviewed a document titled, "Grievances and Complaints Resolution" that documented, "...In the absence of the Risk Manager the CEO [Chief Executive Officer] or the CNO [Chief Nursing Officer] will fulfill the duties of the Risk Manager in respect to the grievance..."

4. Surveyors asked CEO who handled complaints and grievances previous to the new Risk Manager. The CEO told surveyors that no one did and the hospital dropped the ball. The CEO acknowledged that the hospital was not following their complaints and grievance resolution policy.

Based on observation, document review, and staff interviews, the hospital failed to ensure that patients received care in a safe setting.

Findings:
1. On December 16, 2015 at 1:35 p.m. surveyors observed two ambulances backed up with the engines idling, the exhaust pipes pointed directly into the outpatient registration entrance of the hospital. Surveyors walked into the hospital and smelled noxious fumes which spread down the hallway in to the dietary entrance of the hospital.

2. On December 16, 2015 at 1:35 p.m. Staff BBB was coughing. Surveyors asked Staff BBB if she was okay. Staff BBB told surveyors she will be fine once the exhaust fumes stopped coming into the hospital. Staff BBB told surveyors that ambulances have been parking like that for years.

3. Surveyors had the Chief Executive Officer (CEO) meet surveyors by the dietary entrance. The CEO verified the smell of noxious fumes. The CEO and surveyors walked down the long hallway and out the outpatient entrance door to observe both ambulances backed up directly in front of the hospital entrance with the engines idling.

Based on document review and staff interviews, the hospital failed to implement and maintain an effective QAPI (Quality Assessment and Performance Improvement) Program to include all departments of the hospital that was consistent with accepted standards of practice.

Findings:

1. On December 15, 2015 surveyors requested and reviewed QAPI meeting minutes for the past year. There was no documented evidence that the Radiology Services were included in QAPI.

2. On December 16, 2015 at 5:15 p.m. the Radiology Manager provided surveyors with a document titled, "Infection Control Surveillance" dated August 8, 2014 that documented, "...High level disinfecting not being done on Vag probe..."

3. The Radiology Manager told surveyors that she looked into purchasing a high level disinfection system and presented the cost to the Chief Executive Officer (CEO). The Radiology Manager told surveyors high level disinfection was too costly for the hospital to purchase.

4. On December 16, 2015 at 5:15 p.m. the Radiology Manager provided surveyors with a document titled, "Infection Control Surveillance" dated July 31, 2015 that documented, "...Vag prove for ultra sound not being High-level disinfected, after recommendation by CIP, manufacturer's recommendation, Metrex rep and written, read, and sign education and slides..." Surveyors asked the Radiology Manager about the non-compliance specific to vaginal transducer (probe). The Radiology Manager said the high level disinfection system was too costly and was researching other options.

5. On December 16, 2015 at 5:15 p.m. the CEO told surveyors she was unaware that the vaginal transducer (probe) was not properly cleaned.

6. On December 16, 2015 at 6:00 p.m. the Infection Control Practitioner provided surveyors with Infection Control/Employee Health meeting minutes for the past year. The Infection Control/Employee Health meeting minutes dated September 15, 2014 documented the CEO present at the meeting. The meeting minutes documented, "...Ultrasound equipment is not high level disinfected as recommended..." There was no documented evidence of follow up or an action plan.

7. On December 16, 2015 at 6:00 p.m. surveyors asked the Director of Quality to provide the documented evidence where the deficient practice in Radiology specific to the vaginal transducer (probe) was identified, discussed and action taken. The Director of Quality told surveyors there was no documented evidence in QAPI meeting minutes regarding Radiology and the deficient practice identified specific to the vaginal transducer (probe).

8. Surveyors reviewed QAPI meeting minutes for the past year with specific documented evidence of Organ Procurement, Grievances, and Restraints. There was no documented evidence that Organ Procurement, Grievances, and Restraints were included in QAPI.

9. On December 16, 2015 at 6:00 p.m. Surveyors asked the Director of Quality for the documented evidence of Organ Procurement, Grievances, and Restraints. The Director of Quality told surveyors that not all departments report to QAPI.

Based on observations, staff interview and document review, the hospital failed to prepare and manage drugs according to accepted standards of practice.

Findings:

~ On the morning of 12/15/2015, in the anesthesia room, the surveyor found two syringes with needles containing liquid - one labeled Narcan (4 milliliters) and the other labeled Ephedrine (6 milliliters) on the anesthesia cart. Staff MM stated the syringes were from a case the prior week.

(Contaminated sharps (such as needles...) must be immediately discarded in a closable, puncture resistant, leak proof...receptacle. AORN [Association of peri-Operative Registered Nurses] 2013)

~ On 12/16/2015 at 11:28 a.m., Staff OO administered an unlabeled syringe to the patient prior to an upper endoscope Staff OO verbally identified the liquid as viscous lidocaine to the patient prior to administering the medication.

During the same procedure, Staff MM carried a tray of medication to the patient's bedside, and administered three unlabeled syringes.

On 12/17/2015, the Staff JJ stated that all syringes should be labeled.

The pharmacist stated that the expectation for syringe stated the expectation for syringe labeling consisted of: medication name, dose, and expiration date.

The hospital policy titled, "Medication and Sterile Field:, documented, "...Label should identify the medication name, strength, and amount, if not apparent on the container..."

(Unlabeled syringes pose a significant risk when injectable products are prepared in clinical areas. Pharmacy & Therapeutics 2010)

Based on observations, staff interviews, and document review, the hospital failed to:

a. ensure vaginal transducer radiological equipment was properly cleaned and stored in accordance with nationally accepted standards of practice;

b. ensure intravenous and oral contrast was stored in accordance with manufacturers guidelines;

c. ensure patient care equipment was properly used and cleaned in accordance with nationally accepted standards of practice;

d. ensure single use patient care equipment was not used on multiple patients;

e. ensure patient care supplies were properly stored with nationally accepted standards of practice and in accordance with manufacturer's guidelines;

f. include radiology services in the hospital-wide QAPI process;

Findings:

Surveyors toured the radiology department with the Radiology Manager on December 16, 2015 at 1:50 p.m. and December 17, 2015 at 10:00 a.m. where the following observations and interviews were made:

1. A vaginal transducer was stored in a plastic bag labeled, "Mammo pad" wrapped in a white bath towel. The facility was not storing the vaginal transducer according to the manufacturer's guidelines. The Radiology Manager told surveyors that the vaginal transducer was stored in the plastic bag (labeled Mammo pad) which was wrapped in a white patient bath towel to protect the vaginal transducer.

2. Surveyors asked the Radiology Manager what the manufacturer's instructions and guidelines were for cleaning and storing the vaginal transducer. The Radiology Manger told surveyors that the hospital used a modified cleaning and storing process. The Radiology Manger told surveyors the ultrasound technicians followed the process below for cleaning and storing the vaginal transducer:

~took white plastic bag labeled Mammo pad off shelf
~removed vaginal transducer from white plastic bag labeled Mammo pad
~unwrap vaginal transducer from white bath towel
~place/prop up vaginal transducer on unmade patient gurney
~wipe off vaginal transducer with Cavicide wipe quickly
~spray vaginal transducer with TS spray and wipe vaginal transducer off with white washcloth
~take ultrasound gel bottle (that was refilled multiple times from larger ultrasound gel bottle) and apply enough gel on transducer tip
~take vaginal transducer cover (from unsealed bag that contained multiple transducer covers) and cover vaginal transducer
~apply more ultrasound gel on vaginal transducer cover
~hand patient vaginal transducer to insert
~The ultrasound technician removes the vaginal transducer and waits for the patient to leave the room before cleaning the Ultrasound Machine and vaginal transducer.
~The ultrasound technician wiped down the Ultrasound Machine and vaginal transducer with Cavicide
~The gurney that the patient was laying on was wiped with Cavicide
~The vaginal transducer gets wrapped in the white bath towel and white bag it was unwrapped from and placed back on the shelf where it was stored

3. The Radiology Manager told surveyors that on August 2014 and July 2015 she was told that the vaginal transducer needed to be high level disinfected. The Radiology Manager told surveyors that the ultrasound technicians received information and education regarding high level specific to the vaginal transducer. The Radiology manager told surveyors that using high level disinfection was too costly for the facility therefore the ultrasound technicians cleaned and stored the vaginal probe like they have since 2009, which was when the facility purchased the equipment.

4. On December 16, 2015 at 1:50 p.m. and 5:15 p.m., surveyors asked Radiology Manager for manufacturer's cleaning and storage guidelines. The Radiology Manager told surveyors she was unable to find the manual for the ultrasound equipment.

5. Surveyors asked the Radiology Manager for the hospital's policy and procedure on cleaning and storing the vaginal transducer. The Radiology Manager told surveyors that she created the policy and procedure in 2009. A document titled, "Disinfecting Ultrasound Unit" was provided to surveyors on December 16, 2015 at 5:15 p.m. that documented, "...The Transvag transducer should be wiped down with Cavicide and sprayed with PI Spray (T-Spray)...This probe stays in the department and isn't connected to unit unless it is being used..."

According to the FDA, Cavicide is a surface disinfectant and not intended for use with medical devices that enter the body. Cavicide is EPA registered but not FDA cleared for use on medical devices that interact with the body (http://www.metrex.com/sites/default/files/content/education-file/education-file-upload/CaviCide1_EPA_master_label.pdf.)

6. The hospital's policy and procedure doesn't follow nationally recommended infection prevention guidelines. In 2015, according to APIC (Association for Professionals in Infection Control and Epidemiology), the CDC (Centers for Disease Control and Prevention), and the FDA (Food and Drug Administration), vaginal probes are considered semi-critical equipment that need high level disinfection (a complete elimination of all microorganisms in or on an instrument, except for a small number of bacterial spores) between patients. The hospital's policy and procedure to clean and store vaginal transducers did not follow nationally recognized practices/guidelines.

7. On December 17, 2015 at 9:40 a.m., the ultrasound manual was provided to surveyors. The manufacturer's manual was published in 2008 and the Radiology Manager told surveyors that the facility purchased the ultrasound equipment in 2009. The Radiology Manager told surveyors that she was not aware of current cleaning and storage information from the manufacturer. The manufacturer's manual had phone numbers listed of Regional Clinical Application Representatives. Surveyors asked the Radiology Manager if she was able to get clinical support/information from the Regional Clinical Application Representative. The Radiology Manager told surveyors she did not ever call the Regional Clinical Application Representative for cleaning or storage information.

8. On December 17, 2015 at 11:08 a.m., surveyors called the Regional Clinical Application Representative and asked what the manufacturer's recommendation was in regards to cleaning and storing of a vaginal transducer. The Regional Clinical Application Representative told surveyors that the manufacturer's recommendation was to follow a National Infection Prevention Organization recommendation as the manufacturer's guidelines are outdated. The Regional Clinical Application Representative told surveyors that the vaginal transducer can be stored on the ultrasound stand where the ultrasound monitor resided or can be properly stored in a location that could be protected from damage and contamination. The Regional Clinical Application Representative recommendation was to follow a National Infection Prevention Organization such as the CDC (Center for Disease Control and Prevention) or APIC (Association for professionals in Infection Control and Epidemiology).

9. Surveyors reviewed Infection Control Surveillance reports that were dated August 12, 2014 and July 31, 2015 provided from the Radiology Director on December 16, 2015 at 5:15 p.m. The Infection Control Surveillance reports identified deficient practices specific to the vaginal transducer and high level disinfection not being done. There was no documented evidence that there was any action taken past the identification of the deficient practice.

10. The thermostat in the CT (computed tomography) Scan room in the Radiology Department read 65°F (Fahrenheit). There were 22 bottles of injectable intravenous (IV) contrast stored in a glass cabinet. The manufacturer's guidelines printed directly on the label documented, "Protect from light" and "Store at 68-77° F." There were 14 bottles of oral Barium Sulfate contrast stored in the glass cabinet on the same shelf. The manufacturer's guidelines printed directly on the label documented, "Store at 68-77°F."

11. Surveyors asked the Radiology Manager how the temperature was monitored to ensure the IV and oral contrast was kept at the recommended temperatures. The Radiology Manger told surveyors the radiology technicians did not monitor the temperature. Surveyors asked the Radiology Manager how the IV contrast was protected from light as indicated by the manufacturer on the IV contrast bottles. The Radiology Manager told surveyors that she was not aware nor was the other radiology technicians.

12. Surveyors asked the Radiology Manager who ordered the IV and Oral contrast for the Radiology Department. The Radiology Manager told surveyors that she, the Radiology Manager orders the IV and Oral Contrast.

13. Surveyors asked the Radiology Manager who was the Medical Director over the Radiology Department. The Radiology Manager told surveyors she did not know but if any radiology technician needed guidance that the radiology technicians would call the tele-radiologist (a contracted radiologist who is off-site).

14. Surveyors reviewed the organization chart that was provided to surveyors on December 15, 2015 by hospital administration. The Medical Director over Radiology was not the tele-radiologists (contracted service) as indicated by the Radiology Manager. The Medical Director of Radiology was Staff GG. The Radiology Manager told surveyors that she did not report problems to the Medical Director. The Radiology Manager told surveyors she reports serious problems to the Chief Executive Officer.

15. A slider board (to assist in moving patients) handles were wrapped with cotton woven gauze (single use patient care item used for dressing changes). The cotton woven gauze was visible soiled. Surveyors asked the Radiology Manager why cotton woven gauze was wrapped around the handles in multiple locations on the slider board. The Radiology manager told surveyors that the cotton woven handles were used as extension handles on the slider board. There was no documentation by the manufacturer that documented cotton woven gauze was approved for extension handles for slider boards. manufacturer's guidelines and nationally recognized standards of infection control practice doesn't recommend cleaning cotton woven gauze.

16. Surveyors asked the Radiology Manager how the cotton woven gauze was cleaned. The Radiology Manager told surveyors that radiology technicians took CaviWipes and soaked the gauze to clean the gauze.

17. Single use oxygen extension tubing was wrapped around the oxygen tree (device where oxygen tubing is connected for oxygen source) hanging down with connector (that hooks up to patient oxygen) laying on floor.

18. Surveyors asked the Radiology Manager why the oxygen extension tubing was wrapped around the oxygen tree with the connector laying on the floor. The Radiology Manager told surveyors that the radiology technicians hook patients up to oxygen with the extension tubing. Surveyors asked the Radiology Manager when the oxygen extension tubing was changed. The Radiology Manager told surveyors they don't change the oxygen extension tubing. The Radiology Manger told surveyors the oxygen extension tubing is used on all patients.

19. Ultrasound transmission gel was stored in multiple bottles that were visibly soiled with hard/dried transmission gel and brown dirt like substance on the plastic single use plastic bottles. The facility was not following the manufacturer's guidelines when storing and handling ultrasound transmission gel. The manufacturer's guidelines documented, "...Store in original package. Discard unused portion..."

20. Non-sterile ultrasound probe covers for the vaginal transducer was open and not stored as per manufacturer's guidelines.

21. Surveyors reviewed QAPI (Quality Assessment Performance Improvement) meeting minutes for the last year. There was no documented evidence that the deficient practice (identified by Infection Control in 2014 and 2015) was ever mentioned or addressed in QAPI.

22. The QAPI Director was unable to find or provide documented evidence in QAPI meeting minutes where the vaginal transducer cleaning and storage practice was identified as a problem, what solution was taken, and how the hospital was ensuring compliance with the identified problem.

Based on review of infection control documents, policies and procedures, and meeting minutes, surveyors' observations and staff interviews, the hospital failed to:

a. maintain a safe and sanitary environment in all areas of the hospital with ongoing surveillance to ensure infection control standards of practice and policies and procedures were adhered;

b. maintain an ongoing active effective infection control program designed for the prevention, control, and investigations of all infections and communicable diseases; and

c. maintain an ongoing infection control program that reviews surveillance data, hospital practices and infections/communicable diseases, analyzes data on these practices and infections, develops qualitative plans of actions to and provides follow-up to ensure corrective actions are appropriate, working and sustained. Hospital leadership failed to ensure infection control concerns and issues are reviewed, analyzed and corrective actions are taken through the quality assessment and performance improvement process.

Findings:

Observations:

1. Radiology Department -
~ The vaginal transducer (ultrasound probe) was not disinfected by high level disinfection as recommended by infection control standards of practice and the hospital's infection control preventionist. Radiological staff told the surveyors that they used Cavi-Wipes to wipe down the instrument. (On 12/16/2015, the infection control practitioner/preventionist told the surveyor that the product representative stated Cavi-Wipes was not meant for use on this type of equipment.) See Tag A-528 for details on this observation.

~ On 12/15/2015, the surveyors noted 20 intravenous bags were out of the protective outer wrappers. The bags did not contain dates to document the date they were removed from the outer wrappers. Radiology staff told the surveyors they were unaware the bags needed to be dated after removal.

~ See Tag A-528 for other infection control observations in Radiology.


2. Surgical Services Department -
a. On 12/15/2015 between 11:15 a.m. and 3:30 p.m., the surveyors observed the following:
~ At 1:15 p.m., Staff V entered the semi-restricted corridor in street clothes. After entering the semi-restricted corridor in street clothes, Staff V put a plastic gown over the street clothes. The street clothes were still exposed.

~ The surveyors observed Staff ZZ in the semi-restricted corridor and in one of the operating rooms with a a plastic gown over street clothes with the street clothes still exposed. Staff ZZ's facial hair was exposed.

Staff JJ told the surveyors that all staff entered directly into the semi-restricted area from the public corridor in street clothes.

(AORN [Association of peri-Operative Registered Nurses] 2013 guidelines concerning semi-restricted or restricted areas, recorded...Personnel are required to wear surgical attire and cover all head and facial hair.)

~ Surgical scrubs were stored in the open without covering to ensure cleanliness and protection from dust and soil.

~ The restricted and semi-restricted areas, including the operating rooms contained unprotected papers, equipment and supplies in the open that could not be disinfected appropriately as required by acceptable standards of practice - For example, but not limited to:
i. A copier in the corridor;
ii. Supplies that were not kept in water resistant packaging; and
iii. Plastic shower curtain(s), hung over open shelves, had gaps at the top and sides and did not cover the entire openings.

~ Endoscopes were not managed in accordance with acceptable standard of practice. Staff KK stated they did not have a process for reprocessing endoscopes that had not been used for 5 days.

The surveyors requested a policy for the reprocessing of stored endoscopes in not used within a specified time frame. None was provided.

~ At 12:18 p.m., the surveyors observed one of two endoscopes hung in the storage closet with buttons and electrical cap in place. The endoscope was an Olympus brand.

(The Olympus Manual specified all removable parts of the endoscope were to be detached when hung. By removing the air/water valve, biopsy valve, air will circulate through the internal lumens of the endoscope and assist in drying.)

~ The operating room had holes in the walls and mini blinds on the window.

b. On 12/16/2015 at 11:00 a.m., Staff KK was observed mopping the operating room after a surgical case. Staff KK used a string mop and did not change the mop head. Staff KK stated mop heads were changed at the end of the day.

Hospital policy titled, Surgical Suite Cleaning between Cases and Terminal Cleaning, recorded, "...Mop heads are one-time use and placed in designated containers."

~On 12/16/2015 at 3:30 p.m., Staff XX and YY told the surveyor only string mops were used throughout the hospital, including surgery, and were changed after every three rooms. They stated the only time the mop heads were changed after one use was if the patient was in isolation. Standard of practice requires mop heads to be changes after each use/patient room.

(AORN 2013 specify reusable string and microfiber mops and cleaning cloths should be changed after each use.) This is also a standard of practice recommendation by APIC (Association for Professionals in Infection Control and Epidemiology) for hospital-wide cleaning of patient care areas, including the surgical suite.

c. On 12/16/2015 at 11:20 a.m., Staff U failed to disinfect the IV (intravenous) injection port prior to administering medication.

(CDC [Centers for Disease Control] 2007 concerning safe injection practices requires, "...The following recommendations apply to the use of needles, cannulas that replace needles, and where applicable intravenous delivery systems. Use aseptic technique to avoid contamination of sterile injection equipment...")

d. On the morning of 12/16/2015, the surveyor observed Staff OO removed the cell phone in her pocket and answered it with the contaminated gloves (gloves she had use to start the patient's IV) still on her hands.

(Standard of practice per AORN 2013, and CDC - Hand-washing/hand hygiene should be performed after patient contact.)

e. On 12/16/2015, the circulating nurse, who was not gowned leaned on the patient's bedside rails during the patient's endoscopic procedure.

(AORN 2013 guidelines - Peri-operative personnel must wear fluid resistant attire during activities that generate splashes, spatters.)

f. See Tag A-940 for details on Surgical Services observations.


3. Physical Therapy - On 12/16/2015 at 12:30 p.m., surveyors observed the following:
a. In the treatment room, a bottle of ultrasound gel was open for patient use and was not dated. Staff QQ told the surveyors that the gel was refilled from a large gel container in the Radiology Department. Staff QQ told the surveyors she did not know the self life of the ultrasound gel.

b. Surveyors observed a patient's medication stored in the refrigerator located in the Physical Therapy Department. There was no documentation of temperature logs on the refrigerator. Staff QQ told the surveyors she did not know the temperature of the refrigerator and did not know at what temperature range the medication should be stored.

~ The freezer section of the refrigerator was full of ice with ice packs buried under the ice. Staff QQ told surveyors the ice packs had not been used in a long time.

c. Linens for patient use were stored in the open without protective covering. Storage in this manner could not ensure cleanliness and protection from durst and soil.

4. Dietary - On 12/16/2015 at 1:35 p.m., surveyors observed the following:
~ Multiple areas of the kitchen contained corrugated boxes. Corrugated boxes cannot be cleaned and disinfected.

~ Cork boards were observed in the kitchen. Cork boards cannot be disinfected.

~ Multiple areas of the kitchen contained paper and scotch tape, which cannot be disinfected.

~ The kitchen area contained an oscillating fan blowing air into the dishwashing area.


5. Overflow rooms for Outpatients - On 12/15/2015, the surveyors noted the rooms to be dusty. Emergency Department staff, Radiology Department staff and Housekeeping staff interviewed all denied responsibility to keep the area clean and sanitary.


Infection Control Data and Meeting Minutes:

The surveyors reviewed the meeting minutes containing Infection Control data, including Infection Control/Employee Health meetings and Quality (QAPI) meetings, for the period of 08/2014 through 10/2015.

1. Infection control surveillance data documented the person responsible for Infection Control, Staff E, had found problems with departments during environmental rounding. Repeated visits to the same areas showed problems still existed - for example: cardboard boxes in the kitchen area. The cardboard boxes were still present when the surveyors visited the area on 12/15/2015.

~ Meeting minutes reviewed did not demonstrate Infection Control concerns contained in the surveillance data were analyzed, with appropriate corrective actions taken and follow-up conducted to ensure corrective actions were achieved and sustained.


2. Infection Control meeting minutes for 09/15/2014 - Staff E reported, that during the rounds in the Radiology Department, ultrasound equipment was not being high level disinfected as recommended. The action plan for this finding was to send the "rounding documents to department managers."

~ Infection Control meeting minutes for 10/21/2014 did not show any follow-up to the identified problem. This was confirmed on 12/16/2015 at 6:00 p.m. with the staff who was responsible for keeping the minutes.

~ No other meeting minutes reviewed, containing Infection Control data, showed any follow-up to the deficient practice in Radiology, specific to the vaginal transducer probe, that was identified recorded in the 09/15/2014 meeting minutes. On 12/17/2015 at 10:35, Staff E stated she did not follow-up on the ultrasound probe until 07/31/2015.

~ Surveillance data, concerning the Radiology Ultrasound, from environmental round showed on 07/31/2015, Staff E again found that the vaginal transducer probe was not being disinfected according to standards of practice.

No meeting minutes for Infection Control was provided for 08/2015 and 09/2015. On 12/16/2015, Staff E stated no Infection Control meetings were held for those months.

The meeting minutes for 10/06/2015 containing Infection Control data did not contain the reports of the 07/2015 surveillance of the Radiology Ultrasound. This was confirmed with the staff responsible for the meeting minutes. She stated the surveillance was not presented.

3. On 12/16/2015, Staff E told the surveyors Physical Therapy Department and Pharmacy were not included in the surveillance conducted by Infection Control. Staff E stated she did not go to those departments.

~ Surveillance documents recorded only one surveillance in 2015 for Dietary, Respiratory and Laundry. The surveillance data documented visits/environmental rounds to the Emergency Department six times.

4. Although Medical Staff identified a physician as the Medical Director for Infection Control, meeting minutes did not record any physician attended the meetings.

~ Staff E stated on 12/16/2015 at 2:15 p.m. that a physician did not attend the meetings.

5. Meeting minutes and surveillance data for Surgical Services Department did not demonstrate the infection control problems identified by the surveyors for this area had been identified with corrective actions taken to correct the problems.

6. The Infection Control review of 2014 showed one of two abdominal hysterectomy patients developed an infection (50%), but the minutes did not demonstrate a review of the cases with analysis to ensure no problems were identified or that any processes needed to be changed to improve patient outcome.

Based on medical record review, staff interview, and discharge planning policy and procedure review the hospital failed to ensure all patients that needed discharge planning were identified. This occurred in 1 (#19) of 5 ( #12, 14, 19, 20, & #21 )open and closed medical records where discharge planning was reviewed.

Findings:

1. On 12/16/2015 at 2:35 p.m. staff L, the case manager told surveyors that she did not consistently document discharge planning needs in the patient's medical record.

2. On 12/16/2015 at 4:00 p.m. surveyors reviewed a policy titled, "Case Management - Documentation Policy," The policy documented, "...When case management services are provided to a patient, clear and concise entries must be made in the patient's medical record in order to communicate with physicians, nurses, and other personnel involved in the patient's care..."

3. On the afternoon of 12/17/2015 surveyors reviewed 5 ( #12, 14, 19, 20, #21) open and closed medical records. One (#19) of five medical records reviewed did not contain documentation a screening was done to identify if the patient needed a discharge planning evaluation.

Based on medical record review, staff interview, and discharge planning policy and procedure review the hospital failed to ensure each patient who needed discharge planning was provided a discharge planning evaluation. This occurred in 1 (#19) of 5 ( #12, 14, 19, 20, & #21) open and closed medical records where discharge planning was reviewed.

Findings:

1. On 12/16/2015 at 2:35 p.m. staff L, the case manager told surveyors that she did not consistently document discharge planning needs in the patient's medical record.

2. On 12/15/2015 at 4:00 p.m. surveyors reviewed a policy titled, "Case Management - Documentation Policy," The policy documented, "...When case management services are provided to a patient, clear and concise entries must be made in the patient's medical record in order to communicate with physicians, nurses, and other personnel involved in the patient's care..."

3. On the afternoon of 12/17/2015 surveyors reviewed 5 (#12, 14, 19, 20 & #21) open and closed medical records. One (#19) of five medical records reviewed did not contain documentation a screening was done to identify if the patient needed a discharge planning evaluation.

Based on observations, staff interviews, and document review, the hospital:

a. failed to preserve the Surgical Department's original design; thereby, creating improper movement of patients and personnel.
b. failed to maintain three distinct areas of unrestricted, semi-restricted, and restricted in the surgical department, and
c. failed to provide adequate storage spaces for the surgical equipment and supplies within the surgical department.

Findings:

12/15/2015 at 11:15a.m.-3:30 p.m., surveyors toured the Surgical Department. The following findings resulted from the hospital 's repurposing the Surgical Department. The elimination of an unrestricted entry, improper location of a nursing office, and inadequate storage areas increased contaminants being brought into and through the semi-restricted corridor, and created areas that were not maintained according to acceptable standards of practice.

The hospital did not provide a policy that defined the required areas within the Surgical Department, nor the functions of the areas.

Hospital provided a floor plan for the Surgical Department. The following areas were changed from their original design. The room currently used as the chapel was originally labeled "lounge", the office adjoining the chapel was originally labeled, "Staff Locker", and the nursing office was originally titled "Sterile Pack".

1. The Chief Nursing Officer stated "years ago", the staff entrance had changed with the conversion of the staff locker room into the chapel. This change resulted in the personnel, patients, and visitors, wearing street clothes, entered directly into the semi-restricted corridor.

(A transition zone exists where one can enter the area in street clothing and exit into the semi-restricted or restricted zone surgical attire. The traffic in this area is limited to authorized personnel and patients. Personnel are required to wear surgical attire and cover all head and facial hair. AORN 2013)

The staff was utilizing a patient care bathroom in the pre-op area for their personal grooming. During this tour, in a bathroom with a shower, the surveyor saw a hair dryer, comb, and manicure scissors. Staff JJ stated the bathroom was designated for the patients; however, Staff KK periodically showered in it.

2. An office/lounge for surgery nursing personal was established in a room originally designated as a restricted space for sterile supplies. This room was only accessible by going through the semi-restricted corridor or entering through Central Processing, a restricted area. Outside items such as food, coats, Christmas decorations were in this area. Staff OO stated the nursing office/ lounge had been in this room for at least 3 years.

(Work flow patterns should be designed to ensure that contaminants are contained AAMI 2014)

Due to the lack of sufficient storage in the Surgery Department, the following issues were observed:

3. Sterile Supplies were stored in both the operating and procedure room. These supplies were on multiple shelves that were inadequately enclosed and protected.

4. The semi-restricted corridor contained a copy machine, a stretcher covered office supplies and papers, two wheel chairs, patient supplies, and a trash can. Staff JJ stated the semi-restricted hallway was used to prepare charts.

5. Supplies were seen on top of cabinetry close to the ceiling in anesthesia room, soiled utility, and pre-op areas. Staff JJ stated the items should not be stored at that level.

A hospital policy, dated 8/2011, titled "Storage of Supplies- Hospital Wide" documents, "No materials are stored within 18 inches of the ceiling or a fire sprinkler".

6. The pre-op area contained the following equipment at stored in the corner of the room: defibrillator, suction, and cautery. Staff JJ stated the equipment was out of service and was not used.

Based on hospital document review, personnel file review, and staff interviews, the hospital failed to ensure staff working in the emergency department (ED) had demonstrated specialized skills competencies for working in the ED. This occurred for five (Staff B, K, O, AA, and WW ) of five staff files reviewed.

Findings:

1. On December 17, 2015 at 10:30 a.m., staff training and education files were reviewed for evidence of demonstrated skills competencies for specialized tasks performed in the emergency department:

-Triage Assessment using the emergency severity index (ESI) based on Emergency Nurses Association (ENA) and Agency for Healthcare Research and Quality (AHRQ) guidelines;

-Intravenous (IV) insertion, accessing/de-accessing implanted central venous devices, venous blood draw sampling, and blood glucose monitoring using the Association for Vascular Access (AVA) guidelines;

-Neurological assessment using Glasgow coma scale (GCS) based on the ENA;

-IV conscious sedation, rapid sequence intubations (RSI), and airway management based on American Society of Anesthesiologists guidelines;

-Calculating and managing critical IV drips; and

-Restraints used in the ED

None of the personnel files reviewed had documentation of verification of skills competencies related to specialized tasks in the ED.

2. On December 16, 2015, Surveyors reviewed the hospital's ED triage log.

A. 90% of the ED triage log documented patients were triaged incorrect.

The facility used a three level triage system based on the Emergency Severity Index (ESI).

Level 1-Emergent Critical (immediate life, limb or eye threatening requires immediate resuscitation)

Level 2-Urgent (requires prompt care, not in need of immediate resuscitation)

Level 3-Non-Urgent (requires evaluation, time is not a critical factor)

~Patients presenting to the ED with chest pain were triaged as a level 3.
According to the ESI chest pain patients are considered high risk until proven not to be cardiac ischemia requires immediate interventions.

~Patients presenting to the ED as unresponsive were triaged as a level 2.
Any unresponsive patient until proven otherwise is high risk and requires immediate interventions.

~Patients presenting to the ED with suicidal ideation (SI) and or homicidal ideation (HI) were triaged as a level 3.
Any patient declaring SI or HI are proven to be high risk and requires immediate interventions.

~A patient presenting to the ED as a code blue (patient was in cardiac arrest and brought in by the ambulance crew and the ambulance crew were performing chest compressions) was triaged as a level 2.
Any patient in cardiac arrest is high risk and life saving interventions and resuscitation are needed.

~A patient presenting to the ED with an animal bite was triaged as a level 4.
This hospital works on a three (3) tier/level system.

B. The ED Manager verified that 90% of patients on the ED log were triaged incorrectly.

C. Surveyors asked the ED Manager what staff triaged ED patients. The ED Manager told surveyors that all RN's in the ED and the Charge Nurses on the Medical-Surgical Floor can triage patients.

D. Five (Staff B, K, O, AA, and WW) of five personnel files reviewed for triage competencies. None of the files had contained documented evidence of triage competencies.

3. On December 15, 2015 at 3:30 p.m., the ED Manager told surveyors the hospital had not provided skills competency training and had not performed competency testing specific to Triage assessment; accessing/de-accessing implanted central venous devices; neurological assessment using the GCS; IV conscious sedation and RSI, and restraint competencies for nursing staff that worked in the ED.

4. On December 15, 2015 at 3:30 p.m., surveyors requested the hospital's policy for patients' presenting to the ED. The ED Manager provided surveyors with a hospital document titled, "All Patients presenting to the ED" that documented, "...all patients presenting to the Emergency Department shall be triaged by a Registered Nurse (RN) within 15-20 minutes of their arrival to the ED..."

The hospital's policy does not follow the national standard of practice. According to the ESI, there are many high risk situations (such as but not limited to the following: chest pain, cardiac arrhythmias, myocardial infarction, stroke, respiratory distress, uncontrolled bleeding, ripping abdominal pain, diabetic ketoacidosis, sepsis, compartment syndrome, laboring pregnant women, febrile newborns, patients presenting with an overdose, severe pain/uncontrollable pain, occular emergencies) which require immediate life saving interventions and would not be appropriate to wait 15 to 20 minutes.

5. The hospital's policy documented, "...If there are more than 4 patients to be triaged at any one time, the Charge Nurse on the Med-Surgical Floor is notified for additional staff during times of high volume in the ED..."