HospitalInspections.org

Based on document review and staff interview, it was determined based on data analysis, the hospital failed to institute interventions and identify areas needing improvement. This has the potential to affect all patients receiving services by the Hospital (average daily census of 50).

Findings include:

1. The "2015 Quality Improvement Plan and Program Description" (approved 12/8/14) was reviewed. The plan required (page 5 and 11) 'Quality Program Implementation... Use of analytics to identify gaps, opportunities for improvement and Best Practice * Evidence that progress towards goals is checked *Adjustments to plan that are supported by data * Implementation of counter measures..."

2. A review of the Hospital Quality Committee meeting minutes for January, February, March and April 2015 were reviewed on 7/22/15. The committee meeting minutes for "Professional Practice" (medication errors) and "Falls" were reviewed. The Quality, Professional Practice and Falls committee meeting minutes lacked documentation that interventions for improvement were implemented.

3. During an interview on 7/23/15 at approximately 11:00 AM, E#12 (Quality) stated "I'm on the Quality committee." E#12 was unable to verbalize if any fall prevention or medication error reduction interventions were implemented. E#12 verbally agreed interventions and performance improvement data was not analyzed by the Quality committee.

Based on document review and interview, it was determined the Quality Assessment Performance Improvement (QAPI) program failed to ensure Infection Control problems were monitored. This has the potential to affect all patients receiving services by the Hospital (average daily census of 50).

Findings include:

1. A review of the Hospital Quality Committee meeting minutes for January, February, March and April were reviewed on 7/22/15. The Infection Prevention and Control report noted no meeting had been conducted and no data was presented.

2. During an interview on 7/23/15 at approximately 11:00 AM, E#12 (Quality) stated "I'm on the Quality committee." E#12 verbalized that infection control data is being collected such as hand hygiene compliance due to poor compliance rates. E#12 verbally agreed infection control interventions and performance improvement data was not analyzed by the Quality committee.

Based on document review and interview, it was determined that Quality Assessment Performance Improvement (QAPI) program failed to provide monitoring related to all services. This has the potential to affect all patients receiving services by the Hospital (average daily census of 50).

Findings include:

1. A review of the Hospital Quality Committee meeting minutes for January, February, March and April 2015 were reviewed on 7/22/15. The Quality Indicator report lacked indicators for Cardiovascular Services, Care Management, Diagnostic Services, Facilities and Obstetrics.

2. During an interview on 7/23/15 at approximately 11:30 AM, E#12 (Quality) stated "all areas are suppose to have indicators. It's hard to get everyone to choose an indicator. I know the departments monitor data but it doesn't get reported out at Quality."

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Based on document review, observation and staff interview, it was determined the Hospital failed to ensure the prevention of cross contamination. This has the potential to affect all staff, visitors and patients serviced by the Hospital both inpatients and outpatients.

Findings include:

1. The Hospital policy "Medication Management Storage" (revised 1/16/15) was reviewed on 7/23/15 at approximately 11:00 AM. The policy required under "Procedure VI Expiration date stickers will be used to relabeled multidose vials with a revised expiration date (beyond use date) when MDV are opened".

2. The policy titled "Isolation Guidelines Transmission Based Precautions" ((last reviewed 6/24/14) was reviewed on 7/22/15 at approximately 3:00 PM. The policy required "Standard Precautions- USED FOR CARE OF ALL PATIENTS.... 6. Environmental Cleaning ... cleaning of environmental surfaces... bedside equipment, and transport equipment is done whenever contaminated and between patients.

3. The policy titled "Isolation Precaution Techniques" (revised 6/26/2014) was reviewed on 7/21/2015 at 2:00 PM. The policy noted "VI. F. Every member of the direct health care team has the responsibility to meticulously observe proper procedures and techniques. Additionally each employee is responsible for teaching those procedures and techniques to those individuals in contact with the patient, such as the patient's family...who are not familiar with isolation techniques". The policy titled "Isolation Guidelines: Transmission Based Precautions" (revised 9/26/13) was reviewed on 7/21/2015 at 2:30 PM. The policy noted ".. Don gloves and gown prior to entering the room."

4. During an observational tour with the Patient Care Manager of the Intensive Care Unit (ICU) (E#9) on 7/20/2015 at approximately 12:00 PM, ICU room#7 was observed to have an isolation precautions sign posted. Two family members were observed in the patients room with an isolation gown hanging around their neck with their arms exposed. Neither family member had on gloves. Both family members voiced they had not received education regarding isolation.

During an interview on 7/20/2015 at 1:30 PM, E#9 stated "The Hospital policy of infection control was not being followed."

5. During an observational tour of the offsite cancer center on 7/21/15 at approximately 2:00 PM, the refrigerator in the pharmacy had an employee's Tupperware container of a jelly-like substance stored on top of medications.

During an interview on 7/21/15 at approximately 2:00 PM, E#10 (staff pharmacist) stated "I don't know what that is doing in there... it shouldn't be."

6. During an observational tour of the Intensive Care Unit on 7/20/15 with Patient Care Manager (E#9) at approximately 12:00 PM, an EZIO kit (easy interossous kit) was found on a counter top that contained a 20 milliliter (ml) vial of 2% Lidocaine Hydrochloride with 5 ml remaining in the vial. There was no open date or expiration date on the vial.
An interview with E #9 on 7/20/15 at 12:00 PM was completed. E #9 stated that the multidose vial should have been dated upon opening.

7. During an observational tour on 7/22/15 at approximately 11:30 AM, Pt #20 was observed to have an IV pump. On top of the IV pump available for patient use was a pre-filled 10 ml Sodium Chloride syringe labeled as single use with 6 ml's remaining in the syringe.

During an interview on 7/22/15 at approximately 11:45 AM, E#3 (Inpatient Nursing Director) stated "Used flushes (Sodium Chloride pre-filled syringes) should be discarded after use."

8. During an observational tour on 7/22/15 at approximately 12:45 PM, Pt #19 was observed to have an IV pump. On top of the IV pump available for patient use was a pre-filled 10 ml Sodium Chloride syringe labeled as single use with 8 ml's remaining in the syringe.

During an interview on 7/22/15 at approximately 1:00 PM, E#3 stated "Used flushes (Sodium Chloride pre-filled syringes) should be discarded after use."


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