HospitalInspections.org

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Based on document review and interview, in eleven (11) of eleven (11) Personnel Files, the Governing Body did not ensure that: (A) Contracted Emergency Department (ED) Physicians and Physician Assistants (PAs) attended initial hospital orientation, reviewed hospital ED Policies and Procedures and Medical Staff Bylaws, Rules and Regulations, and completed hospital mandatory classes upon orientation and annually; and (B) A corrective action plan was implemented timely for ED Physicians and Physician Assistants.

Findings pertinent to (A) included:

The Personnel Files for Staff N (PA/Physician Assistant) hired on 11/01/15, and Staff O (MD/Medical Doctor) hired on 07/01/17, lacked evidence they attended hospital orientation, had reviewed hospital ED Policies and Procedures and Medical Staff Bylaws, Rules and Regulations, and completed hospital mandatory classes upon orientation and then annually.

The same lack of education was found in the Personnel Files for Staff Members P (MD), Q (PA), R (MD), S (PA), T (MD), U (MD), V (PA), W (MD) and X (MD).

Per interview of Staff Y (CMO/Chief Medical Officer) on 03/06/19 at 11:40AM and 1:20PM, Staff Y confirmed these findings. Staff Y shared that it is the expectation for all Physicians, including ED Physicians, to attend hospital orientation. This is performed during the credentialing process. The ED Physicians and Physician Assistants did not go through orientation, and they should have done so.

Per interview of Staff Z (CNO/Chief Nursing Officer) on 03/06/19 at 2:00PM, Staff Z confirmed there were no signed attestations from the forty (40) ED Physicians or Physician Assistants confirming they had reviewed the ED Policies and Procedures and Medical Staff Bylaws, Rules and Regulations.

The facility Policy and Procedure titled, "Orientation and On-going Education" last revised 05/02/17, described the following: "All new employees must attend the Hospital-Wide Orientation Program, which is scheduled at the time of hire. Orientation will be completed prior to an employee working independently. The Hospital-Wide Orientation Program includes but is not limited to...patient confidentiality and ethics...emergency procedures, infection control...."

The facility Policy and Procedure titled, "Annual Mandatory Education" last revised 03/23/17, described the following: "All employees and contract employees are required to complete annual mandatory education...."

Findings pertinent to (B) included:

The Meeting Minutes for the facility's Administrator On-Call (AOC) Report dated 01/22/19 - 01/29/19, revealed that on 01/22/19, an ED Physician violated a patient's privacy. The hospital's corrective action plan included ED staff education on maintaining patient privacy and restricted cell phone use. As of 03/07/18, approximately one (1) month after the event, fourteen (14) of the forty (40) Physicians and Physician Assistants had not yet completed the education.

Per interview of Staff Z on 03/06/19 at 2:00PM, Staff Z confirmed that these fourteen (14) Physicians and Physician Assistants still required the education. She could not offer a reason why the education had not been completed.
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Based on Medical Record review, document review and interview, in three (3) of three (3) Medical Records reviewed, the facility did not ensure that Care Plans were complete or updated to reflect the patient's medical condition.

This failure to complete or update Care Plans potentially placed patients at risk for delays to care and treatment.

Findings include:

Review of Patient #19's Medical Record identified that this patient was admitted on 03/01/19 with diagnoses of Stroke, TIA (Transient Ischemic Attack), Depression and other multiple co-morbidities.

During interview of Staff EE (RN/Registered Nurse) on 03/04/19 at 11:00AM, Staff EE stated that during her assessment of Patient #19, this patient complained of feeling depressed.

The Care Plan for Patient #19 did not contain any documented evidence of the patient's history of Depression, or a diagnosis, goals, or interventions for Depression.

The same problem of incomplete/non-updated Care Plans was found for Patients #21 and #22.

These findings were confirmed by Staff EE, Staff K (Director of Nursing Critical Care Services), and Staff M (Nurse Educator) on 03/04/19 at 11:00AM.

The facility Policy and Procedure titled "Department of Nursing Plan of Care" last revised 08/08/18, contained the following statements: "Based on the medical diagnosis and the information gathered during the assessment and history taking, the nurse formulates the patient care plan according to identified care needs...care plans must be individualized according to the patient care needs."
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Based on observation, document review and interview, in two (2) of two (2) observations of blood glucose testing, the facility did not ensure that staff provided care within acceptable standards of Infection Control Practices.

These lapses in Infection Control Practices placed patients at increased risk for infections.

Findings include:

Observations in the facility's 4-South Unit during a tour between 11:00AM and 12:00PM on 03/04/19 identified the following:

Staff EE (RN/Registered Nurse) was observed performing glucose testing on Patient #20. Staff EE touched the patient during the identification process with gloves on and without changing gloves or performing hand hygiene, proceeded to open the bottle of glucose test strips and retrieved a strip, contaminating the bottle.

Staff EE was then observed retrieving two (2) gauze pads from a sleeve of gauze pads and Sani-Wipes from a dispenser with the contaminated gloves on. After the staff member completed the blood glucose testing, she placed the contaminated packet of gauze pads and bottle of glucose test strips inside the medication cart.

Staff FF (RN) was observed performing blood glucose testing on Patient #22. Immediately after testing the patient's blood glucose, Staff FF was observed cross-contaminating supplies and equipment. Staff FF then placed the contaminated supplies and equipment on her medication cart, then failed to clean the contaminated surface.

These observations were made in the presence of Staff K (Director) who confirmed these findings.

The facility Policy and Procedure titled "Blood Glucose Monitoring" last revised 08/24/17, lacked guidance directing the staff when to change gloves and perform hand hygiene during blood glucose testing.
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Based on Medical Record review, document review and interview, the facility failed to perform timely radiological testing for patients meeting the facility's trauma criteria, in two (2) of four (4) Medical Records reviewed.

Findings include:

The Policy and Procedure titled, "Trauma Activation Procedure" last reviewed 05/03/18, stated: "...to assure that patients with concerning MOI [ Mechanism of Injuries] are seen in an expeditious manner and to prevent delay in detecting possible injuries...activation of a trauma alert criteria includes for an Adult, having a fall from any height if taking a blood thinner...all imaging studies will be given priority in the Emergency Department (ED). Based on the MOI, either Triage Nurse or ED provider will have trauma alert activated. The patient will be triaged immediately to an acute bed in the ED...X-Ray, CT and Laboratory will prioritize workups for these patients when the alert is called. All lab work and imaging studies for these patients will take priority in the ED."

Review of Patient #1's Medical Record identified the following: Patient #1, with a history of taking Xarelto [a blood thinning medication], presented to the ED on 01/14/19 at 12:42PM via ambulance. Patient #1 had fallen, then subsequently hit her head. Patient #1 denied complaints of nausea, vomiting or numbness. An Emergency Severity Index (ESI) Level 2 was assigned. The ED Physician ordered a Trauma Alert Activation at 12:54PM. The Trauma Alert Order Set included a CT scan of the head. The ordered CT scan was not performed until 4:50PM, four (4) hours after the CT Order was placed. There was no documented evidence as to why the CT scan was delayed for this length of time.

Review of Patient #2's Medical Record identified the following: This 61-year-old arrived at the ED by ambulance on 01/12/19 at 2:54PM. Patient #2 had fallen at home and was on Plavix [a blood thinning medication]. An ESI Level 2 was assigned. The Physician ordered a Trauma Alert Activation at 2:55PM which included a CT scan of the head. The CT scan of the head was not performed until 5:58PM, three (3) hours after the Order was placed.

Two (2) days later, on 01/14/19 at 12:40PM, Patient #2 returned to the ED by ambulance after once again falling at home. Patient #2 was still on Plavix. An ESI Level 2 was assigned. The Physician ordered a Trauma Alert Activation, including a CT scan of the head, at 1:00PM. The CT scan of the head was not performed until 6:59PM, six (6) hours after the Order was placed. There was no documented evidence as to why the CT scan was delayed for this length of time.

Per interview of Staff F (Director of Radiology) on 03/05/19 at 11:20AM, the ED has a dedicated CT Scanner and all Radiological Tests in the ED are ordered "Stat". The Trauma Alerts are a higher priority than a "Regular Stat". However, because there are no clear and distinct thresholds or criteria for this category, they [Trauma Alerts] won't necessarily be performed as an immediate high priority. The Regular Stat CT scans are performed in the order we receive them, unless a Physician calls us to say do it immediately. It would be better if the wording were changed because as of now, 100% of all the Radiology Tests ordered in the ED are ordered Stat." Upon request of a facility Policy and Procedure listing the sublevel types of Stat Orders and their respective criteria, Staff F stated that the facility does not have such a Policy.

On 03/05/19 at 12:00PM these findings were discussed with Staff A (Assistant Vice President of Quality) who acknowledged these findings.