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Based on review of the facility's policy and procedures, medical record (MR) and an interview it was determined physician's order was not appropriately written according the hospital policy that affected Patient Identifier (PI) # 23. This affected 1 of 1 records reviewed for restraints and had the potential to affect all patients served.

Findings include:

Subject: Use of Restraints
Reviewed: 05/11

Purpose: ...This facility creates and environment that helps hospital staff focus on the patient's well being. Our goal is an organization- wide approach to restraints that protects the patient's health and safety and preserves his or her dignity, rights and well being.

This facility ensures that restraint interventions are safely and appropriately used....

V. Procedures

E. Orders for Restraints
Written or verbal orders for initial and continuing use of restraints are time limited.
i) ... Physicians ordering restraint must have a working knowledge of hospital policy regarding restraint
a) Be for each use of the restraints and related to a specific episode of the patien's behavior and not for unspecified future time or episode. ...

1. PI # 23 was admitted through the Emergency Department of the hospital on 3/29/18 with the diagnosis of Increased Agitation, Hallucination and Altered Mental Status.

Review of the Physician's Order dated 3/29/18 at 8:45 PM revealed the following order: Chemical Restraint and Physical Restraint for patient safety. May use 4 point/ Vest Posey restraints as (PRN) needed for patient and staff safety. May administer Ativan 1 mg. (milligram), Benadryl 50 mg. and Haldol 5 mg IM (intramuscular) x 1 dose PRN

An interview was conducted with Employee Identifier (EI) # 2, Director of Nursing on 10/4/18 at 11:00 AM confirmed the staff failed to follow facility's policy and procedures.

Based on review of the facility's policy and procedures, medical record (MR) and a interview it was determined the staff failed to monitor Patient Identifier (PI) # 23 while placed in a 4 (four) point Vest Posey jacket,. This affected 1 of 1 records reviewed for restraints and had the potential to affect all patients served.

Findings include:

Subject: Use of Restraints
Reviewed: 05/11

Purpose: ...This facility creates and environment that helps hospital staff focus on the patient's well being. Our goal is an organization- wide approach to restraints that protects the patient's health and safety and preserves his or her dignity, rights and well being.

This facility ensures that restraint interventions are safely and appropriately used....

IV. Policy:

iv) Monitor and meet the patient's needs while in restraints.
v) Reassess and encourage the release of restraints as soon as possible

V. Procedures:

E. Orders for Restraints

iv) ... Standing or PRN (As needed) orders for restraints are not acceptable.

viii) Content of Individual Orders:
Time limited.

F. Periodically Assessing, Assisting And Monitoring The Patient In Restraint

ii) A Registered Nurse must assess the patient at established timeframes.
Assessment, as appropriate to the type of restraint includes:

nutrition/ hydration
circulation and range of motion in the extremities

iii) Care provided at least every 2 (two) hours to include:
offer fluids/ nourishment
hygiene care as required
toileting as required
release of extremities and range of motion exercises provided.

iii) Documentation
Each episode of restraint is documented in the patient's medical record on the Restraint Flowsheet, consistent with policies and procedures.

vii) All assessments and monitoring of the patient.
viii) Patients response to the intervention, including the rationale for continued use of the intervention.

1. PI # 23 was admitted through the Emergency Department of the hospital on 3/29/18 with the diagnosis of Increased Agitation, Hallucination and Altered Mental Status.

Review of the Physician's Order dated 3/29/18 at 8:45 PM revealed the following order: Chemical Restraint and Physical Restraint for patient safety. May use 4 point/ Vest Posey restraints as (PRN) needed for patient and staff safety. May administer Ativan 1 mg. (milligram), Benadryl 50 mg. and Haldol 5 mg IM (intramuscular) x 1 dose PRN.

Review of the Registered Nurse (RN) Initial Interview Form dated 3/29/18 at 10:51 PM and Daily Nursing Assessment dated 3/3018 at 9:40 AM revealed there was no documented care and assessment provided to the patient every 2 hours to include reassessment of the restraints and physical needs of the patient such as hydration.

An interview was conducted with Employee Identifier (EI) # 2, Director of Nursing on 10/4/18 at 11:00 AM confirmed the staff failed to follow facility's policy and procedures.

Based on record review, interview and hospital policy the nursing staff failed to assess and document wounds, document specific wound care that was provided and follow physician orders for wound care. This affected Patient Identifier (PI) # 21, 1 of 1 wound care chart reviewed.

Findings include:

Subject: Wound Care
Revised 01/16

Policy
It is the policy of Evergreen Medical Center to evaluate patient with a wound on admission or that develops after admission and obtain treatment orders from the physician.

All treatment will be documented in the Electronic Health Record.

Procedure
1. The following information will be evaluated and documented by the nurse
a. Location of the wound
b. Stage if a decubitus and ...
c. Dimensions (Length x Width x Depth) in centimeters. Length being head to toe and width being side to side. ...

3. If when nursing is performing the dressing change and a worsening of the wound is noted, the physician should be notified for changes in treatment.

1. PI # 21 was admitted on 5/25/18 with the primary diagnosis of Diabetic Foot Ulcer.

Review of the Physician's Order Sheet 5/25/18 revealed wound care order as follows: Wet to dry dressing to foot every 12 hours.

Review of the Admission Nursing Admission dated 5/25/18 at 8:15 AM, 8:50 PM, revealed the Registered Nurse (RN) failed to document the wound depth and wound care dressing as ordered by the physician.

Review of the Daily Nursing Assessments dated and 5/26/18 at 8:45 AM and 9:00 PM, 5/27/18 at 8:18 AM and 9:45 PM, 5/28/18 at 9:34 AM, 5/29/18 at 9:33 AM and 10:54 PM, 5/30/18 at 10:45 AM and 10:03 PM, 5/31/18 at 10:14 AM and 9:30 PM, 6/1/18 at 7:48 AM and 11:16 PM, 6/2/18 at 7:50 AM revealed the RN failed to assess, perform and document wound care every 12 hours according to the physician's orders.

An interview was conducted on 10/14/18 at 11:10AM with Employee Identifier (EI) # 2, Director of Nursing who confirmed the above mentioned findings.

Based on review of medical records (MR), policy, and interview with staff it was determined the hospital failed to ensure:

a) Physician's signatures included the date and time.

b) Consents for Anesthesia Services contained date and time signed by witnesses, including the RN (Registered Nurse) and CRNA (Certified Registered Nurse Anesthetist) signatures.

This affected 6 of 6 surgery records reviewed and did affect Patient Identifier (PI) # 1, PI # 2, PI # 3, PI # 4, PI # 5, PI # 6 and had the potential to affect all patients served by the hospital.

Finding include:

Policy: Medical Staff Policies and Procedures
Date Approved: 2/8/18

"...Medical Records

...6.) Clinical Entries

All clinical entries in the patient's medical record should be accurately dated, timed, and signed."

*****

1. PI # 1 was admitted to the hospital on 5/23/18 with a diagnosis of Chronic Tonsillitis. The patient was scheduled for a Tonsillectomy on 5/23/18.

Review of the MR revealed a H&P dated 3/28/18. The electronic physician's signature contained no date or time.

Review of the MR revealed an Operative Procedure note dated 5/23/18. The electronic physician's signature contained no date or time.

Review of the Consent for Anesthesia Services form dated 5/23/18 contained no date and time the form was witnessed by the RN and CRNA.

During an interview conducted on 10/4/18 at 10:24 AM with Employee Identifier # 3, Operating Room (OR) Supervisor, the above findings were confirmed.

2. PI # 2 was admitted to the hospital on 6/4/18 with the diagnosis of Recent Gastric Ulcer, and scheduled for a Esophagogastroduodenoscopy (EGD).

Review of the MR revealed a Surgical Consultation dated 5/9/18. The electronic physician's signature contained no date or time.

Review of the MR revealed an Operative Procedure note dated 6/4/18. The electronic physician's signature contained no date or time.

During an interview conducted on 10/4/18 at 10:24 AM with EI # 3, the above findings were confirmed.

3. PI # 3 was admitted to the hospital on 6/11/18 for a Screening Colonoscopy.

Review of the MR revealed a H&P dated 5/30/18. The electronic physician's signature contained no date or time.

Review of the MR revealed an Operative Procedure note dated 6/11/18. The electronic physician's signature contained no date or time.

During an interview conducted on 10/4/18 at 10:24 AM with EI # 3, the above findings were confirmed.

4. PI # 4 was admitted to the hospital on 7/16/18 with the diagnosis of Chronic Osteomyelitis with Exposed Bone Left Great Toe and Left Second Toe. The patient was scheduled for amputation of left great toe and left second toe.

Review of the MR revealed a H&P dated 7/2/18. The electronic physician's signature contained no date or time.

Review of the MR revealed an Operative Procedure note dated 7/16/18. The electronic physician's signature contained no date or time.

During an interview conducted on 10/4/18 at 10:24 AM with EI # 3, the above findings were confirmed.

5. PI # 5 was admitted to the hospital on 7/23/18 with diagnoses including Symptomatic Cholelithiasis, and Abscess Left Groin. The patient was scheduled for a Laparoscopic Cholecystectomy and I (Incision) and D (Drainage) Abscess Left Groin.

A review of the MR revealed a H&P dated 7/11/18. The electronic physician's signature contained no date or time.

Review of the MR revealed an Operative Procedure note dated 7/23/18. The electronic physician's signature contained no date or time.

Review of the Consent for Anesthesia Services form dated 7/23/18 contained no date and time the form was witnessed by the RN and CRNA.

During an interview conducted on 10/4/18 at 10:24 AM with EI # 3, the above findings were confirmed.

6. PI # 6 was admitted to the hospital on 7/9/18 with the diagnosis of Right Inguinal Hernia. The patient was scheduled for a Right Inguinal Hernia Repair with Mesh.

A review of the MR revealed a H&P dated 6/25/18. The electronic physician's signature contained no date or time.

Review of the MR revealed an Operative Procedure note dated 7/9/18. The electronic physician's signature contained no date or time.

During an interview conducted on 10/4/18 at 10:24 AM with EI # 3, the above findings were confirmed.

Based on review of the facility's policies, observations, and interviews it was determined the facility failed to ensure

1. All expired medications were removed and not available for patient use.

2. All medications available for patient use were correctly labeled according to facility policy.

This had the potential to negatively affect all patients served by this facility.

Findings include:

Policy: Medication Area Review
Subject: Medication Area Review Policy
Revised Date: 1/2018

Policy:

"The director of pharmacy or his qualified designee shall inspect all areas where medications are administered or stored. This shall be done monthly. A report shall be prepared and shall include,....

4. Labeling
5. Out-dated, discontinued, recalled, and unusable drugs..."

Policy: Licenses, Privileges, and Medications
Subject: Medication-Who May Dispense
Revised Date: 8/15/18

Policy:

"Labeling requirements: Name of medications, Strength, Preparation Date, Expiration Date, Preparer's Name, Lot Number"


1. A tour of the facility pharmacy was conducted on 10/3/18 at 9:45 AM with Employee Identifier (EI) # 9, Pharmacy Director.

The surveyor observed the following medications on the pharmacy shelves and available for patient use:

Bottle labeled as Ferrous Sulfate Elixir with no documentation of the strength, preparation date, expiration date, preparer's name, or lot number.

Bottle labeled as Rynex DM 5 ml (milliliter) UD (unit dose) elixir with no documentation of the preparation date, expiration date, preparer's name, or lot number.

Bottle labeled as Hydroxyzine 10 mg (milligrams)/5 ml with no documentation of the preparation date, expiration date, preparer's name, or lot number.

Bottle labeled as Cypropheptadine Syrup 2 mg/ 5 ml 60 ml bottle with no documentation of the preparation date, expiration date, preparer's name, or lot number.

Bottle labeled as Rondec DM with no documentation of the strength, preparation date, expiration date, preparer's name, or lot number.

Levetiracetam 100 mg/ ml with documented expiration date of 2/18.

Medroxy-progesterone Acetate 10 mg tablet with documented expiration date of 9/18.

Provera 10 mg tablets x (times) 9 tablets with documented expiration date of 9/18.

The previous findings were verified by EI # 9, prior to surveyor leaving pharmacy.

2. A tour of the facility Emergency Department was conducted on 10/3/18 at 1:00 PM with EI # 6, Registered Nurse (RN).

The surveyor observed the following medications in the Pyxis (medication dispensing system) and available for patient use:

Bottle labeled as GI (Gastrointestinal) Cocktail (Mylanta 10 oz (ounce), Bentyl 4 oz, Viscous Lidocaine 2 oz) 1 dose equal to 30 ml with no documented expiration date.

Hydrogen Peroxide 3 % (percent) with documented expiration date of 3/18.

25 % Mannitol 250 mg / ml x 2 vials with documented expiration date of 10/1/18.

Haloperidol Injection IM (Intramuscular) 1 ml (5 mg) x 3 ampule's with documented expiration date of 3/13.

5 % Dextrose Injection 1000 ml with documented expiration date of 8/18.

EI # 6 confirmed the expiration dates prior to surveyor leaving the Emergency Department.

An interview was conducted on 10/3/18 at 2:30 PM with EI # 2, Director of Nursing, who verified the previous findings.

Based on policy review and interview with Employee Identifier (EI) # 10, Laboratory Director, it was determined the facility failed to ensure a system was in place to take appropriate action when notified that blood or blood components it received are at increased risk of transmitting Human Immunodeficiency virus (HIV) or Hepatitis C Virus (HCV).

This had the potential to negatively affect all patients receiving blood or blood products.

Review of the policy and procedure book on 10/3/18 at 10:45 AM revealed there was no policy or procedure available for identifying the correct procedure for dealing with Infectious Blood and Blood Products.

On 10/3/18 at 1:45 PM, EI # 10 gave surveyor a copy of "Policy and Procedure for Quarantine of Blood Product(s)" for facility.

Review of the facility Policy and Procedure for Quarantine of Blood Product (s) revealed no documentation of the date policy and procedure was reviewed and accepted by the facility.

The Surveryor asked EI # 10, for documentation of when the Policy and Procedure for Quarantine of Blood Products (s) was reviewed and accepted by the facility. EI # 10 then verbalized that the policy and procedure was created on 10/3/18 and did not have a signature(s) for the acceptance of the policy and procedure to the facility.

An interview was conducted on 10/4/18 at 7:52 AM with EI # 1, Chief Operations Officer, confirmed there was no policy or procedure for dealing with Infectious Blood and Blood Products prior to 10/3/18.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to negatively affect all patients served by the facility.

Findings include:

Refer to Life Safety Code violations

Based on observations, review of CDC guidelines and interviews, it was determined the staff failed to:

a) Perform hand hygiene per policy.

b) Maintain reusable equipment per facility policy

This affected unsampled patient # 1, unsampled patient # 2, and unsampled patient # 3 from the Operating Room (OR) department, and had the potential to negatively affect all patients served by the facility.


Findings include:

CDC Guidelines to Hand Hygiene Volume 51, Published 2002

Recommendations

"1. Indications for handwashing and hand antisepsis

B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described in items 1C-J. Alternatively, wash hands with an antimicrobial soap and water in all clinical situations described in items 1C-J.

C. Decontaminate hands before having direct contact with patients.

F. Decontaminate hands after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient).

G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled.

H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care.

I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.

J. Decontaminate hands after removing gloves ..."


Policy: Management of Clean Equipment
Effective Date: 10/2004

"Purpose: To ensure appropriate technique in maintaining clean equipment.

Policy:

...III. ...When equipment is shared, disinfection of equipment should take place prior to next patient use."


1. An observation visit was conducted on 10/4/18 at 9:45 AM in the Emergency Department with EI (Employee Identifier) # 6 RN (Registered Nurse) to observe an IV (intravenous) placement on unsampled patient # 1.

At the end of the IV placement EI # 6 secured IV with a transparent dressing then removed glove to right hand. Glove to left hand remained in place on EI # 6 left hand.

EI # 6 then used right hand to search both left and right side pockets of uniform and stated she/he was looking for a marker without performing hand hygiene after glove was removed.

After EI # 6 searched pockets of uniform and was unable to find a marker, EI # 6 donned glove to right hand without hand hygiene prior to donning of glove.

Facility staff failed to perform hand hygiene according to the CDC guidelines and perform hand hygiene after removing glove.

An interview was conducted on 10/4/18 at 9:59 AM with EI # 2, Director of Nursing, who confirmed the previous findings.

2. An observation visit was conducted on 10/4/18 at 9:15 AM with EI # 5, RN, on the medical surgical floor to observe a medication pass with IV administration on unsampled patient # 2.

After administration of oral medication, EI # 5 donned gloves and prepared Protonix for IV administration without performing hand hygiene prior to gloves being donned.

After IV Protonix administration, EI # 5 gathered trash and placed in the trash then opened door to patient room with gloved hands and existed patient room to obtain a supply that was needed from the nursing station without removing gloves or hand hygiene prior to leaving patient room.

Facility staff failed to remove contaminated gloves and perform hand hygiene according to the CDC guidelines.

An interview was conducted on 10/4/18 at 10:01 AM with EI #2, who confirmed the previous findings.


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3. An observation was conducted on 10/3/18 at 7:49 AM, of a colonoscopy performed on unsampled pt # 3 in the endoscopy room of the OR department.

During the procedure, the circulating RN assisted in the biopsy of a polyp. The physician ordered more sedation for the patient. The circulating RN removed her/his gloves and failed to perform hand hygiene before retrieving additional medication.

Following the colonoscopy, EI # 3, OR Supervisor, suctioned clean solution through the used scope, laid the scope on machine, removed gloves, and failed to perform hand hygiene before donning clean gloves. EI # 3 carried the scope to the cleaning room, immersed the scope in disinfectant, cleaned the scope lumens with disposable brush and removed gloves. EI # 3 failed to perform hand hygiene before donning a new pair of gloves. EI # 3 placed the scope in the automatic washer, along with the used guide wire. EI # 3 removed her/his gloves and failed to perform hand hygiene.

An interview was conducted on 10/4/18 at 10:37 AM with EI # 3, who confirmed the above findings.

This Condition of Participation is not met as evidenced by:

Based on observations in the surgery department, review of facility surgery policy and procedure manuals, and interview with staff, it was determined the facility failed to:

a) monitor and document temperature and humidity levels in the Operating Room (OR), Procedure room, Central Sterile Processing and Storage. A 951

b) perform preventative maintenance on Surgery and Central Sterile equipment. A-951

c) maintain an environment in the endoscopy suite free of pests. Refer to A-951

d) ensure staff followed hospital policy for OR attire. Refer to A- 951

e) history and physicals were updated prior to procedures requiring anesthesia services.
Refer to A-952

f) provide control of traffic in the OR and Central Sterile departments. Refer to A-956

This had the potential to negatively affect all patients served by the facility.

Findings include:

Refer to A940, A951, A952 and A956 for findings.

Based on observations in the surgery department, review of facility surgery policy and procedure manuals, and interview with staff, it was determined the facility failed to:

a) monitor and document temperature and humidity levels in the Operating Room (OR), Procedure room, Central Sterile Processing and Storage.

b) perform preventative maintenance on Surgery and Central Sterile equipment.

c) maintain an environment in the endoscopy suite free of pests.

d) ensure staff followed hospital policy for OR attire.

e) provide control of traffic in the OR and Central Sterile departments.

These deficient practices have the potential to affect all patients served by the hospital.

Findings include:

Policy: Infection Control: Pest Control
Effective Date: October 2004

"Purpose: To provide an environment free of pests.

Policy: The facility will have a pest contract that provides frequent treatment of the environment for pests...

There will be emphasis on the pest control program in... central sterile supply, operating rooms...

Monitoring of the environment will be done by the facility's staff. Pest control problems will be reported promptly..."

Policy: Attire, Surgical
Date Reviewed: 06/17

"Purpose

Surgical attire provides a barrier between personnel and between patient... through which contamination may pass.

Policy

All personnel entering restricted areas of the surgical suite shall be in Operating Room attire.

OR attire consist of standard cotton scrub suit..., shoe covers and a standard hat, hood, or bonnet. Operating Room attire which is soiled or wet shall be changed. All reusable attire shall be laundered after each use in the hospital laundry. Operating Room attire shall be stored in an enclosed area. Cover gown or lab coat is to be worn whenver leaving the surgical suite..."

Policy: Traffice Control
Effective Date: October 2004

"Purpose: To provide for control of traffic by personnel and visitors in the hospital.

Policy:

Area: Surgery

The Surgery Suite is kept closed. Only authorized persons are permitted to enter. Limit amount of personnel in surgery suite as much as possible... Visitors and personnel are excluded from the Surgery Suite..."

Policy: Prevention of Cross Contamination
Related to: Surgical Services/ Central Sterile
Date Reviewed: 6/16

"Policy:

The following policies are to be followed for the prevention of cross contamination in Central Service:

- Soiled items are confined to decontamination clean-up area and are kept separated from clean and sterile supplies...

- ...Once monthly, all shelves on which sterile supplies are stored are to be dusted and wiped with alcohol solution. Wipe all sterile storage area monthly or as needed, with hospital approved cleaner...

-Weekly, all surface areas... in the department are cleaned thoroughly with soap and water..."

*****

During a tour of the surgery department on 10/2/18 at 11:15 AM, with Employee Identifier (EI) # 3, OR Supervisor, the surveyor asked to review temperature and humidity logs for the surgery suite and central sterile areas. EI # 3 stated there were no logs kept for temperature and humidity.

In the endoscopy suite the surveyor observed two black insects with wings, floating in the floor stand wash hopper. The sink next to the hopper contained lime stains, an old brush, 3 used cleaning brushes coiled in bottom of sink, a piece of white plastic pipe, bits of white paper, 1 extra purge valve, and an old suction canister used to fill the cleaning container to immerse the endoscopes. The emergency eye wash station was also located at this sink, and was observed to be leaking.

In the OR suite, on the blue anesthesia cart, 1 intubating stylet was observed open and lying out of packaging. On the second anesthesia cart, an Intubating Laryngeal Airway was observed opened, and moisture on the inside of the packaging. No surgery has been performed in the OR suite for over a week due to lighting replacement. Electricians are present during tour.

The surveyor asked EI # 3 to describe their OR attire. EI # 3 explained the nurses wear their personal scrubs to the hospital from home. EI # 3 stated only the scrub nurse wears a cover gown in the OR. The surveyor asked if OR personnel wear a lab coat when leaving the surgery suite area. EI # 3 stated, "No."

The tour continued to Central Sterile, which was located across the hall. An exterior door was located at the end of the hall. The Emergency Room waiting area was also accessed on this hall. During the time the surveyor was on site, multiple visitors were observed on this hall, asking for water or directions. The doors to the surgery suite, endoscopy room, and Central Sterile do not have locked/ controlled entries.

Inside the Central Sterile receiving area, the surveyor observed a plastic bin containing instruments submerged in a liquid. EI # 3 stated those were from the last hernia repair that was performed a week ago. The surveyor observed clean instruments setting on a shelf, on top of an opened sterile pack. EI # 3 explained the used pack was from a doctor's office, "...and she had not had time to come in here and clean all these instruments."

The storage of sterile instrument packs, was located in the room with the sterilizer. Located less than 12 inches above the sterile cloth packs was a sprinkler head. Also located in this room, were 6 shelves containing orthorpedic boots, wrist braces, splints, shoulder immobilizers, cervical collars etc., which EI # 3 stated were used by the ER. EI # 3 also stated the ER staff comes in to retrieve supplies and sterile instruments needed in the ER. There was no control of traffic/ personnel coming in to Central Sterile. The surveyor observed spider webs, dust, and hair on the floor. The surveyor asked if the shelves containing sterile packs were wiped down monthly with an alcohol solution, per policy, and all other surface areas wiped down weekly, per policy. EI # 3 answered, "No."

During an interview conducted on 10/4/18 at 10:37 AM with EI # 3, the above findings were confirmed.

Based on review of medical records (MR), policy, and interview with staff, it was determined the facility failed to ensure the physician updated the History and Physical (H&P) 24 hours after admission or prior to procedures requiring anesthesia services. This affected 6 of 6 surgical records reviewed and did affect Patient Identifier (PI) # 1, PI # 2, PI # 3, PI # 4, PI # 5, PI # 6, and had the potential to affect all patients served by the hospital.

Findings include:

Policy: Evergreen Medical Staff Rules and Regulations/ Policies and Procedures
Date Approved: 2/8/18

"...History and Physical

...2.) Complete history and physical examinations must be performed and documented no more than thirty (30) days before or twenty four (24) (hours) after admission. When using a history and physical performed prior to admission, an update must be documented at the time of admission. This update must be attached to the history and physical, usually writing the update directly onto the previous history and physical. This addendum must be dated and signed by the physician. For patients with no changes, the update may state that the history and physical was reviewed, the patient was examined, and physician concurs with the findings of the history and physical previously performed...

4.) The history and physical examination must be recorded on the medical record prior to any operative or other invasive procedure requiring anesthesia or moderate sedation..."

*****
1. PI # 1 was admitted to the hospital on 5/23/18 with a diagnosis of Chronic Tonsillitis. The patient was scheduled for a Tonsillectomy.

Review of the MR revealed a H&P dated 3/28/18, which was 56 days prior to admission. There was no documentation the physician updated the H&P.

During an interview conducted on 10/4/18 at 10:24 AM with Employee Identifier # 3, Operating Room (OR) Supervisor, the above findings were confirmed.

2. PI # 2 was admitted to the hospital on 6/4/18 with the diagnosis of Recent Gastric Ulcer, and scheduled for a Esophagogastroduodenoscopy (EGD).

Review of the MR revealed a Surgical Consultation dated 5/9/18. There was no documentation the H&P was updated by the physician prior to the procedure.

During an interview conducted on 10/4/18 at 10:24 AM with EI # 3, the above findings were confirmed.

3. PI # 3 was admitted to the hospital on 6/11/18 for a Screening Colonoscopy.

Review of the MR revealed a H&P dated 5/30/18. There was no documentation the H&P was updated by the physician prior to the procedure.

During an interview conducted on 10/4/18 at 10:24 AM with EI # 3, the above findings were confirmed.

4. PI # 4 was admitted to the hospital on 7/16/18 with the diagnosis of Chronic Osteomyelitis with Exposed Bone Left Great Toe and Left Second Toe. The patient was scheduled for amputation of left great toe and left second toe.

Review of the MR revealed a H&P dated 7/2/18. There was no documentation the H&P was updated by the physician prior to surgery.

During an interview conducted on 10/4/18 at 10:24 AM with EI # 3, the above findings were confirmed.

5. PI # 5 was admitted to the hospital on 7/23/18 with diagnoses including Symptomatic Cholelithiasis, and Abscess Left Groin. The patient was scheduled for a Laparoscopic Cholecystectomy and I (Incision) and D (Drainage) Abscess Left Groin.

A review of the MR revealed a H&P dated 7/11/18. There was no documentation the H&P was updated by the physician prior to surgery.

During an interview conducted on 10/4/18 at 10:24 AM with EI # 3, the above findings were confirmed.

6. PI # 6 was admitted to the hospital on 7/9/18 with the diagnosis of Right Inguinal Hernia. The patient was scheduled for a Right Inguinal Hernia Repair with Mesh.

A review of the MR revealed a H&P dated 6/25/18. There was no documentation the H&P was updated by the physician prior to surgery.

During an interview conducted on 10/4/18 at 10:24 AM with EI # 3, the above findings were confirmed

Based on observations, review of the facility's Preventive Maintenance Log, and interviews with staff it was determined the facility failed to ensure all equipment was tested for performance and safety on an annual basis.

This had the potential to negatively affect all patients served by the facility.

Findings include:

Policy: Equipment Care and Maintenance
Policy Number: 1101.8
Date Reviewed: None Listed

"Autoclaves- Central Service personnel are responsible for cleaning and clinical monitoring of all sterilizers."


1. A tour of OR (Operating Room) department was conducted on 10/2/18 at 11:15 AM, with Employee Identifier (EI) # 3, OR Supervisor.

The surveyor requested to see the OR defibrillator and was told by EI # 3 it was located in the PACU (Post Anesthesia Care Unit), a room also used for overflow Emergency Room patients. The surveyor observed the defibrillator in the PACU and it was determined there was no PM (Preventive Maintenance) sticker on the equipment.

A review of the Preventive Maintenance Log dated July 2018, performed by Anatech Inc. (Incorporated), revealed 2 defibrillators had PM performed.

An interview was conducted on 10/2/18 at 11:45 AM with EI # 2, Director of Nursing, who confirmed the hospital had a total of three defibrillators, and the PACU defibrillator failed to have PM performed.

2. A tour of the Central Sterile department was conducted on 10/2/18 at 1:20 PM with EI # 3.

The surveyor observed a Steris Sterilizer and asked EI # 3 when the last PM and cleaning was performed. EI # 3 stated the last maintenance and professional cleaning of the sterilizer had been performed in September of 2015.

During an interview conducted on 10/4/18 at 10:37 AM with EI # 3, the above findings were confirmed.

3. A tour of the only OR suite was conducted on 10/3/18 at 2:00 PM with EI # 3.

The following equipment in the OR failed to have a PM sticker:

a) Zimmer Tourniquet machine on a rolling stand.

b) Ritter stand light with no PM. Two hospital maintenance employees were in the OR suite working on the installation of new overhead lighting. One of the employees stated he/she had brought the light in to the OR from a storage room.

An interview was conducted on 10/4/18 at 10:37 AM with EI # 3, who confirmed the above findings.

Based on review of the Emergency Preparedness Program, review of employee files and interviews with the staff it was determined the facility failed to provide initial or annual training to all the employees for emergency preparedness.

This had the potential to negatively affect all patients served by the facility.

Findings include:

Review of the Emergency Preparedness ( EP) Program and employee files on 10/4/18 at 10:30 AM reveled no documentation of the initial training or annual training for the EP Program.

An interview was conducted on 10/4/18 at 7:56 AM with Employee Identifier (EI) # 1, Chief Operations Officer, who verbalized that the initial EP training was incorporated into the facility's annual orientation.

EI # 1 further verbalized the facility had provided 2 months of annual orientation that included initial EP training.

The surveyor was given two Annual Orientation Sign-in Sheets, by EI # 1 on 10/4/18 at 12:00 PM, dated 8/15/18 and 9/24/18.

Review of the Annual Orientation Sign-in Sheet dated 8/15/18 revealed 6 employee names. No documentation of the title of the employee or what area of the hospital the employee was employed in was documented.

Review of the Annual Orientation Sign-in Sheet dated 7/24/18 revealed 3 employee names. No documentation of the title of the employee or what area of the hospital the employee was employed in was documented.

Review of the Facility List of Employees that was printed and given to the surveyor by the facility on 10/2/18 revealed the facility had a total of 157 current employees.

Based on the previous, the facility had provided initial EP training to 9 of the 157 current employees.

A second interview was conducted on 10/4/18 at 12:00 PM with Employee Identifier (EI) # 1, who confirmed that only the employee's that were listed on the Annual Orientation Sign-in Sheets dated 8/15/18 and 9/24/18 had received initial EP training and that no other EP training has been completed.

Based on review of the Emergency Preparedness (EP) Program and facility staff interview it was determined the facility failed to document facility staff participation in a table top exercise and a community-based exercise.

Findings include:

Review of the EP Program reveled no documentation that the facility performed or participated in a table top or a community-based exercise.

An interview was conducted on 10/4/18 at 12:00 PM with Employee Identifier (EI) # 1, Chief Operations Officer, who verified that the facility had not performed or participated in a EP table top or community-based exercise.