HospitalInspections.org

Based on observation and staff interview, it was determined the Hospital failed to ensure all medical records were maintained in a confidential manner. This has the potential to affect 100% of patients receiving care within the Respiratory Therapy and Cardio-rehabilitation areas.
Findings include:

1. A tour of the Respiratory Department (RD) was conducted on 2/27/13 at 11:00 AM. During the tour an individual, not receiving care in the Respiratory Department, entered the Department to weigh them self, unescorted, thru a hallway that had open treatment rooms with medical information on desks. The CNE immediately escorted the individual out of the RD. The RD had no signs indicating restriction of access or signs indicating patient traffic flow.

2. A tour of the Cardiac Rehabilitation Unit was conducted on 2/27/13 at 12:30 PM, a patient waiting for services in the Cardiac Rehabilitation Unit, walked up to a table where staff watch monitors that record heart rhythms and medical records were present. The waiting area consists of chairs that are up against the table where the staff work, which was within reading sight of medical record information. While this surveyor was conducting an interview with staff at that desk, the patient walked up to the desk and started to read the medical record paperwork that was on the desk. This surveyor immediately covered all the paperwork with blank sheets of paper. The CNE escorted the patient to a chair that was farther away from the table, out of reading sight of patient medical records.

3. An interview with the CNE was conducted on 2/27/13 at 12:40 PM. The CNE confirmed the individual did not have rights to the weight scale in the Respiratory Department without escort. The CNE also confirmed that the patient waiting for Cardiac Rehabilitation should have sat down and not approached the table without command from Hospital Staff.

Based on a review of the Hospital's Performance Improvement Plan, observation, and staff interview, it was determined the Hospital failed to ensure all Hospital departments submitted data, on a quarterly basis, to the Quality Improvement (QI) Coordinator in order to monitor, assess, and improve the quality of care as indicated in the Hospital's Performance Improvement Plan. This has the potential to affect 100% of the patients receiving care at the Hospital.
Findings include:

1. The Hospital policy 2012 Performance Improvement Plan, revised 12/2011, was reviewed on 2/27/13. Under "3. Department Improvement Structure. All hospital departments and medical staff services are involved in collecting data in order to measure either processes, outcomes, performance indicators, high risk, high volume, problem prone procedures or other indicators of performance... The department managers report their activities to the QI Coordinator on a quarterly basis with a written report... Department teams use the FOCUS-PDCA methodology for their performance improvement process."

2. During a tour of the Radiology department, conducted on 2/27/13 at 3:15 PM, a request was made to the department Manager for the quality indicators she was following and reporting to Quality. No documentation was provided that indicated the Radiology department had a quality program.

3. During a staff interview with the Radiology department Manager, conducted on 2/27/13 at 3:25 PM, it was verbalized that for the past year the Radiology department did not identify, collect, or report any quality material. It was stated that administration could not agree on which quality indicators needed to be tracked and reported for the quality improvement program.

4. A staff interview with the QI Coordinator was conducted on 2/27/13 at 9:00 AM. The QI Coordinator confirmed that the Radiology department was not submitting QI data on a quarterly basis. The QI Coordinator also indicated that follow up action was not taken by the QI Department, to ensure Departments were collecting, measuring, analyzing, tracking quality indicators and submitting data to the QI Coordinator on a quarterly basis.

Based on a review of the Hospital's Medical Staff Bylaws, medical record review, and staff interview, it was determined that in 1 of 2 (Pt #10) medical records reviewed of patients who received a cardiac stress test in the Respiratory Department, the Hospital failed to ensure all orders for medication were put into writing.
Findings include:

1. The Hospital Medical Bylaws were reviewed on 2/28/13. Under "SECTION 3. GENERAL CONDUCT OF CARE B. All orders for treatment shall be in writing. All orders dictated over the telephone shall be signed by the appropriately authorized person to whom it was dictated with the name of the practitioner per his or her own name."

2. The electronic medical record (EMR) and paper chart for Pt #10 was reviewed while conducting a tour of the Respiratory Department on 2/27/13 at 1:00 PM. Documentation on the "PATIENT HISTORY AND STRESS TESTING" sheet indicated Pt #10 was scheduled for a Stress Test with Lexiscan. The word Lexiscan is crossed out and the word Cardiolyte is circled. Pt #10 received a stress test on 2/27/13 at 9:30 AM and received Cardiolyte without a physician order.

3. An interview with the Respiratory Manager confirmed that Pt #10 received a Stress Test with Cardiolyte on 2/27/13 at 9:30 AM. The Respiratory Manager indicated the patient was originally scheduled for a stress test with an order for Lexiscan but after conversing with the ordering physician's office on 2/26/13, the Stress Test was changed to one with Cardiolyte. There was no documentation in the paper chart or the EMR to indicate there was a verbal or written order for Pt #10 to receive a stress test with Cardiolyte.

Based on record review and staff interview, it was determined in 3 of 3 (Pt #17, #18, #19) medical records of patients who received a Cardiac Stress Test in the Respiratory Department over 30 days ago, the Hospital failed to ensure all medical tests conducted were authenticated by the physician.
Findings include:

1. The Electronic Medical Record (EMR) and paper chart of Pt #17 was reviewed on 2/28/13. Pt #17 received an outpatient Treadmill Stress Test on 8/1/12. The Physician signature line on the "EXERCISE STRESS TEST REPORT" was blank.

2. The EMR and paper chart of Pt #18 was reviewed on 2/27/13. Pt #18 received an inpatient Lexiscan Stress Test on 10/31/12. The Physician signature line on the "EXERCISE STRESS TEST REPORT" was blank.

3. The EMR and paper chart of Pt #19 was reviewed on 2/27/13. Pt #19 received an inpatient Treadmill Stress Test on 10/3/12. The Physician signature line on the "EXERCISE STRESS TEST REPORT" was blank.

4. An interview with the Medical Records Manager was conducted 2/28/13 @ 11:30 AM. The Medical Record Manager confirmed that the stored closed hard charts as well as the EMR did not contain a physician's signed copy of the "Exercise Stress Test Report" for Pt #17, #18, #19.

A. Based on a review of the Radiology departments Radiation Dosimetry Reports and staff interview, it was determined that the Hospital failed to ensure changes in the dosimetry badge control were investigated and followed up on. This has the potential to affect 100% of the radiology technicians working in the department.
Findings include:

1. The Radiation Dosimetry Reports for the last 12 months were reviewed. Documentation indicated that the control was being reported as minimal until 7/30/12.
The 7/30/12 report indicated a control of 24 millirem (mrem), above the minimum reportable quantity.
The 9/13/12 report indicated a control of 19mrem, above the minimum reportable quantity.
The 11/6/12 / 11/9/12 report indicated a control of 18mrem, above the minimum reportable quantity.
The 1/10/13 / 1/15/13 report indicated a control of 18mrem, above the minimum reportable quantity.

2. During an interview with the Radiology manager, conducted on 2/26/13 at 4:00 PM, it was verbalized that she did not know why the control badge readings were elevated on recent reports and stated that there was no investigation into the reasons why. She stated that the Control Badge is placed in a drawer in the reception area. It was further verbalized that the receptionist (who sits in the reception area), where the control badge is kept, is pregnant. Radiation exposure to the receptionist is unknown since the receptionist does not wear a badge, yet the Control Badge kept in the area she works is above the minimal reportable quantity.

B. Based on a request for documentation and staff interview, it was determined that the Hospital failed to ensure all surgery personnel that had the potential to be exposed to radiation were monitored for radiation exposure. This has the potential to affect 100% of the surgical staff who are present during radiology procedures in the surgical department.
Findings include:

1. A request was made to the Radiology department Manager for the Radiation Dosimetry Reports for personnel exposed to radiation in surgery. No documentation was presented that indicated there were dosimetry reports for those individuals exposed to radiation in surgery.

2. During an interview with the Radiology manager, conducted on 2/26/13 at 4:00 PM, it was verbalized that those personnel in surgery that are exposed to radiation are not monitored for exposure to radiation. It was further stated that she orders the dosimetry badges for Hospital employees that have potential exposure to radiation. She has not ordered dosimetry badges for any surgery personnel since she has been the manager. When asked who oversees the use of dosimeter badges in surgery, it was stated that no dosimeter badges were ordered for those personnel in surgery that are exposed to radiation when the C-arm (an X-Ray device) is used during surgical procedures. She did state that when X-Rays are taken in surgery, all extraneous personnel are asked to leave the room. However, she did state that at least the physician and the circulating nurse remain in the surgical suite during the radiology procedure.

Based on a review of the Laboratory's reference lab log book and staff interview, it was determined that the Hospital failed to ensure the laboratory properly tracked its lab tests sent out to reference laboratories. This has the potential to affect 100% of those patients whose specimens are sent out to reference laboratories.
Findings include:

1. During a tour of the Laboratory, conducted 2/26/13 at 3:30 PM, the laboratory log for tests sent out to reference laboratories was reviewed. The months of Nov and Dec 2012 and Jan 2013 were reviewed. The log book lacked documentation that all specimens sent to reference laboratories were returned to the Hospital's laboratory. In Nov 2012 this occurred 22 times; in Dec 2012 - 9 times; and in Jan 2013 19 times.

2. During an interview with the Laboratory Manager, conducted on 2/26/13 at 4:00 PM, it was verbalized that there was no policy or procedure related to sending tests/specimens out to reference laboratories nor return of test results. She indicated that the far right hand column in the log book indicated that the test/specimen results were received back from the reference laboratory. It was also verbalized that all of the tests/specimens sent out should have a returned date in the far right hand column.

Based on a review of Hospital policy and procedure, observation, and staff interview, it was determined the Hospital failed to ensure dietary personnel were dating opened food items to ensure the quality and safety of food storage and prevention of food borne illnesses. This has the potential to affect 100% of the patients served by the Dietary department.
Findings include:

1. The Hospital policy and procedure titled, "Dietary Services" (with a revised date of 5/10) was reviewed. It indicated under "VI. PROPER FOOD HANDLING L. Leftovers must be dated, labeled with expiration date, covered, cooled and stored..."

2. During a tour of the Dietary department, conducted on 2/26/13 at 3:00 PM, the following were observed to be opened but having no date of opening or expiration on the wrapping: in the 2 door refrigerator - 1 large uncut turkey breast; 1 bag of yellow shredded cheese; 1 bag of white shredded cheese; in the walk in cooler - 1 red velvet cake; in the 3 door cooler - 1 bag finger rolls

3. During an interview with the Dietary Manager, conducted on 2/26/13 at 3:45 PM, it was verbalized that all the opened and stored food items should have been labeled with the opened date and the expiration date. It was also verbalized that re-education of the dietary staff was needed to ensure opened food items were properly labeled.

A. Based on observation and staff interview, it was determined that the Hospital failed to ensure that the air duct louvers in the clean laundry room were properly cleaned to ensure adequate ventilation and prevention of potential contamination by dust/dirt particles onto the clean linen. This has the potential affect 100% of the patients who receive services at the Hospital.
Findings include:

1. During a tour of the Hospital's laundry department, conducted on 2/26/13 at 1:50 PM, it was observed that the louvers of the air duct were dark (blackish) with dust threads hanging off them. When this surveyor swiped the right index finger along the length of one louver, the pad of the right index finger was coated with a dark substance. This was shown to the laundry and environmental personnel in attendance and both agreed that the louvers needed to be cleaned.

2. During an interview with the Director of Environmental Services, conducted on 2/26/13 at 1:55 PM, it was verbalized that the air ducts blow air into the clean laundry room and that assigned maintenance personnel are supposed to clean the louvers of the air ducts on a regular basis. He stated that the assigned maintenance person must have missed the air duct in the clean laundry room.

B. Based on a review of Hospital policy and procedure, medical record review, and staff interview, it was determined that in 2 of 2 (Pts #14, #15) medical records reviewed in which the patient had blood cultures drawn, the Hospital failed to ensure the location of the blood draws was documented to be able to identify a point of reference for subsequent draws if needed.
Findings include:

1. The Hospital policy and procedure titled, "BLOOD CULTURE DRAWING PROCEDURE" (with no reviewed/revised date) was reviewed. It indicated under, "BLOOD CULTURE DRAWING PROCEDURE: 7. Multiple blood culture specimens should be drawn from different sites, if at all possible."

2. The medical record of Pt #14 was reviewed on 2/27/13. It indicated Pt #14 was admitted on 2/26/13 with a chief complaint of weakness and confusion. Documentation in the medical record indicated that Pt #14 had blood cultures drawn on 2/26/13 at 9:30 AM and at 10:30 AM. There was no documentation to identify the sites that the blood cultures were drawn from.

3. The medical record of Pt #15 was reviewed on 2/27/13. It indicated that Pt #15 was admitted on 2/23/13 with a chief complaint of fever and sore throat. Documentation indicated that Pt #15 had blood cultures drawn on 2/23/13 at 1:35 and 2:15 AM. There was no documentation to identify the sites that the blood cultures were drawn from.

4. During an interview with the CNE, conducted on 2/27/13 at 3:45 PM, it was verbalized that there should be documentation to indicate where multiple blood cultures are drawn from. She stated she also checked the lab results in the electronic medical records and that the location of the blood draws were not documented there either.

C. Based on a review of policies and procedures, observation, and staff interviews, it was determined the Hospital failed to prevent the potential transmission of communicable diseases by ensuring a sanitary environment in the laboratory department. This has the potential to affect 100% of patient specimen results reported.
Findings include:

1. The Hospital's policy "Standard Precautions" (reviewed 11/12) indicated under "IX. Lab Specimens: Should be placed in a container that prevents leakage during collection, handling, processing, storage, transport, or shipping and should be labeled with a biohazard symbol.

2. The Hospital's policy "Multidrug Resistant Organisms (MDRO)" (reviewed 11/12) indicated under "Note: ... Another organism requiring the same level of care but not considered resistant is Clostridium difficile (c diff), which is very difficult to kill on surfaces in its spore state ... Excellent environmental cleaning should be done with recommended "wet times" to inactivate the spore. A 1:10 solution of bleach will also be effective against this organism in its spore state.

3. During a tour of the microbiology department on 2/26/13 at 3:55 PM, the following was observed:
A stool specimen with a patient label was observed in the refrigerator. The specimen was in a container on the top shelf above clean, unused agar plates without a specimen bag.
Sani-wipes available for disinfectant were not approved for killing c-diff and an appropriate product for killing c-diff was not identified for use in the microbiology specimen work station. The laboratory tracking log indicated 38 stool specimens were processed for c-diff from 12/1/12 to 2/29/13.

4. During a staff interview conducted on 2/26/13 at 3:55 PM with two microbiology MT's, it was confirmed that the stool specimen identified in the refrigerator had been processed for c-diff and then replaced into the refrigerator by the MT without a biohazard bag. The MT reported "we do this all the time." The process for segregation of a clean supply area from the dirty specimen area in the refrigerator was asked to be clarified. The MT reported there was no process or protocol regarding placement of specimens versus storage of clean supplies. The process for cleaning the refrigerators that contain contaminated specimens was asked to be clarified. The MTs and the Director of Laboratory confirmed there is cleaning of the refrigerator on a "prn" basis only and was unable to verbalize when the last refrigerator cleaning if any had been performed. The process of cleaning the work area where these stool specimens suspected of c-diff are processed was asked to be clarified. The MT and the Director of Laboratory confirmed that the sani-wipes are used on the hard surfaces at the end of the day and a bleach solution was not provided. During an interview conducted on 2/27/13 at 2:30 PM The Director of Laboratory confirmed that she was not aware the wipes were not effective on the c-diff organism.

D. Based on a review of policy and procedure, observation, and staff interview, it was determined the Hospital failed to ensure the prevention of transmission of blood borne pathogens by performing appropriate hand hygiene in the laboratory department. This has the potential to affect 100% patients and specimen results.
Findings include:

1. The Hospital's policy "Hand Hygiene" (reviewed 11/12) was reviewed on 2/27/13. The policy indicated under "I. Indications for handwashing and hand antisepsis...G. Decontaminate hands after contact with body fluids... I. Decontaminate hands after contact with inanimate objects... J. Decontaminate hands after removing gloves."

2. The Hospital's policy "Standard Precautions" (reviewed 11/12) was conducted on 2/27/13. The policy indicated under "I. Gloves should be worn whenever exposure to the following in planned or anticipated: A. Blood/blood products..."

3. During a tour of the laboratory conducted on 2/26/13 at 1:55 PM, the MT was observed removing contaminated gloves without performing hand hygiene. During a tour of the laboratory conducted on 2/27/13 at 2:00 PM - 2:40 PM, three MT's were observed removing contaminated gloves without performing hand hygiene and the Director of Laboratory was observed placing used blood tubing into a biohazard bag without using gloves or performing hand hygiene post exposure.

4. During a staff interview on 2/26/13 at 2:15 PM and 2/27/13 at 2:45 PM, the Director of Laboratory confirmed the breaches in Hand Hygiene that was observed.

Based on a review of the Hospital's Medical Staff Bylaws, medical record review and staff interview, it was determined that in 2 of 3 (Pts #16, #20) surgical records reviewed, the Hospital failed to ensure that approved personnel conducted the post-anesthesia evaluation.
Findings include:

1. The Hospital's Medical Staff Bylaws was reviewed. It indicated under "Section 4. General Rules Regarding Surgical Care F. The anesthetist shall maintain a complete record to include evidence of pre-anesthetic evaluation and post-anesthetic follow-up of the patient's condition."

2. The medical record of Pt #16 was reviewed on 2/28/13. It indicated Pt #16 was admitted on 11/13/12 with a diagnosis of Right Inguinal Hernia Repair. Documentation on the "Anesthesia Preoperative evaluation and care plan" indicated in the area titled, "Post Anesthesia Note" that the post-anesthesia evaluation of Pt #16 was performed by the RNAI (Registered Nurse Anesthesia Intern). It was not co-signed by the anesthetist or the physician to ensure the accuracy/completeness of the evaluation.

3. The medical record of Pt #20 was reviewed on 2/28/13. It indicated Pt #20 was admitted on 10/16/12 with a diagnosis of Tissue Mass/Lesion Removal. Documentation on the "Anesthesia Preoperative evaluation and care plan" indicated in the area titled, "Post Anesthesia Note" indicated that the post-anesthesia evaluation of Pt #20 was performed by the RNAI. It was not co-signed by the anesthetist or the physician to ensure the accuracy/completeness of the evaluation.

4. During an interview with the CNE, conducted on 2/28/13 at 3:45 PM, it was verbalized she was not aware what the responsibilities the RNAI was able to perform independently and was not aware that the post-anesthesia evaluations were being conducted by the RNAI without oversight by the anesthetist or physician.