HospitalInspections.org

Based on observation and interview, the Governing Body failed to;

A. ensure patient received care in a safe setting. Located in the Psychiatric Department 19 of 19 patient rooms had drop down ceilings and unsecured light fixtures that placed all patients at risk for the likelihood of harm to self or others.

Dialysis staff not disinfecting the RO (reverse osmosis) at least monthly as recommended by the manufacture. These findings have the likelihood to cause harm to all patients receiving care in the dialysis unit.

Refer to Tag A0144

B. provide Quality oversight to the contracted Dialysis Service. The Dialysis Service was not reporting to the Quality and Patient Safety Council.

Refer to tag 273

C. ensure the facility had an organized Nursing Department.

1. the Nursing Directors did not have current and correct job descriptions and evaluations in their personnel records.

See Tag A0386

2. the psychiatric patients were not being reassessed at the required intervals to ensure patient safety and stability.

See Tag A0396

3. ensure the safe administration of medication according to hospital policy.

See Tag A0405

4. ensure the safe administration of blood according to the policy and procedure.

See Tag A0409

Based on document review and interview, the Board of Trustees (Governing Body) failed to assure the Medical Staff reviewed Rules and Regulations every two years. The Medical Staff Rules and Regulations provided by the facility for review were dated and approved by the Board of Trustees on 01/09/2014. There was no date of last review.

A review of the Medical Staff Rules and Regulations revealed no evidence of review every two years. The Medical Staff Rules and Regulations were dated and approved by the Board of Trustees on 01/09/2014.

A review of the Board of Trustee Bylaws revealed in 7.2 Medical Staff Governance, "The Medical Staff shall review and revise all Medical Staff Ruled and Regulations, and, as applicable, departmental policies and procedures, when warranted, provided that such review shall occur at least every two (2) years."

An interview in the administrative office with staff #48 confirmed documents titled "Medical Staff Rules and Regulations" were the current rules.

Based on observation and interview, the facility failed to


A.)ensure patient safety for patients in 19 of 19 patient rooms in the psychiatric unit.The rooms had drop down ceilings and unsecured light fixtures that placed all patients at risk for the likelihood of harm to self or others.

These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients that had the likelihood to cause harm, serious injury, impairment and/or subsequent death.

B.) provide proof that newborn infants were secure from potential abduction.

C.) ensure the staff disinfected the RO at least monthly as recommended by the manufacture. These findings have the likelihood to cause harm to all patients receiving care in the dialysis unit.

Refer to Tag A0144

Based on observation and interview, the facility failed to

A.)ensure patient safety for patients in 19 of 19 patient rooms on the psychiatric unit. The rooms had drop down ceilings and unsecured light fixtures that placed all patients at risk for the likelihood of harm to self or others.

These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients that had the likelihood to cause harm, serious injury, impairment and/or subsequent death.

B.) provide proof that newborn infants were secure from potential abduction.

C.) ensure the staff disinfected the RO at least monthly as recommended by the manufacture. These findings have the likelihood to cause harm to all patients receiving care in the dialysis unit.



A.) A tour was conducted of the facility's geriatric psychiatric unit on 1/25/2017 with Staff #1 and #48. A geriatric patient is considered to be 55 and over. During the tour, the private patient rooms were found to have drop down ceilings. Each room had a large wooden armoire with the doors removed leaving shelves exposed. Climbing shelves made access to the ceiling easily accessible. Each room had unsecured light fixtures in the drop down ceiling.

In the psychiatric setting, this provides a place for psychiatric patients to hide medications, weapons, or other contraband. The metal supports for the drop down ceilings can be easily pulled down and used by psychiatric patients to harm themselves or others.

Staff #1 stated that they did not have to have solid ceilings in the geriatric unit. Staff #1 stated they were told by their corporate office that they were "grand fathered in." Staff #1 was given an opportunity to supply the surveyor with any documentation to allow the facility to "grandfather in" drop down ceilings for a geriatric psychiatric unit. Staff #1 was unable to furnish any validity to the claim. Staff #1 and staff #48 confirmed that patients may be at risk.


B.) A tour of the Women's Care Unit and Nursery was performed on 1/25/17. In the Nursery, the babies were identified with their ID bracelets. There was no electronic devices in the nursery or women's care unit to protect the babies from potential abduction.
An interview with staff #57 on 1/25/17 reported the doors to the nursery are locked with a key pad. Only personnel needing access to the nursery have the code. When the babies are not in the nursery they are in the care of their parents.
Review of the policy and procedure "Infant Security" stated, "C. When infant is taken to mother's room, bands numbers are matched and exchange band is taken to nursery and placed on infant's chart. If the mother or other family members go to the nursery to pick up the infant, they must have the exchange band. It will be matched to the infant and placed on the infants chart.
E. Patient will be educated through the Newborn Safety Education form on admission. They will be given a copy of this form. Education will include the band exchange, instructions not to leave the infant unattended in the room, to take the infant to the bathroom when they go if they are alone, send the infant to the nursery when showering or sleeping. If they wish to keep the baby while sleeping they are instructed to place the crib on the side of the bed farthest from the door. They will also be instructed that only Maternal Child Health staff will transport her infant except when she or her authorized family member does so. They will be instructed not to allow their infant to go with a staff member not wearing a badge or having the exchange band."
An interview with patient #70 on 1/26/17 revealed she had just given birth to a baby on 1/26/17. Patient #70 confirmed she had been asleep in the room alone with her baby multiple times.
An interview with staff #56 on 1/25/17 confirmed that the nurse is not always at the nurse's station or has visual of the hallway of the Women's Unit. The nurse could be busy in another patient room. The unit has camera's but is not sure who is watching the cameras. Staff #56 and #57 confirmed that there was a possibility that a baby could be taken off the unit without the staff knowing. Staff #57 reported she has asked several times for a security system to ensure the infant safety but was told they were too expensive.
An interview was conducted with staff #1 concerning the security of the infants on the women's care unit. Staff #1 reported that she had looked at the HUGS (electronic) security system and had put it in the budget and sent to corporate office. Staff #1 reported the system was declined by corporate offices due to costs. Staff #1 reported that she feels the infants would be safer and more secure with an electronic system but it was denied.







22676




C. Findings:
Review of the AmeriWater system instructions stated "As a general guideline, AmeriWater recommends that the system should be disinfected at least monthly."
Review of the disinfection logs for the main RO serial #26180 revealed the staff failed to disinfect the RO in June 2016 and July 2016.
An interview with staff #21 on 01/24/2016 at 3:30 p.m. confirmed the above findings.

Based on document review and interview, the facility failed to provide Quality oversight to the contracted dialysis service. The Dialysis Service was not reporting to the Quality and Patient Safety Council.

Refer to tag 273

Based on record review and interview, there was no evidence the hospital's contract dialysis unit was included in the Hospitals Quality and Patient Safety Council. Citing 6 months (July 21, 2016, August 25, 2016, September 30, 2016, October 27, 2016, November 30, 2016 and December 28, 2016) of 6 months meeting minutes reviewed. These deficient practice had the likelihood to cause harm to patients receiving care in the unit by failure to review the quality of service provided.

In addition, there was no evidence that the dialysis unit and the hospital conducted monthly Quality and Patient Safety Council meetings to review the overall care provided by the unit including nursing care, and technical operation of the unit. These findings have the likelihood to cause harm to all patients receiving care by the contract service.

Findings.

Review of the Hospitals Quality and Patient Safety Council minutes for the months of August 25, 2016, July 21, 2016, September 30, 2016, October 27, 2016, November 30, 2016 and December 28, 2016 revealed there was no review of the contract dialysis company which included the care provided, conductivity meter review, and technical review (including cultures, endotoxin tests, machine maintenance and disinfection, chlorine logs, and water start up logs and disinfection records for all RO's).

Review of a packet provided by the Quality staff # 4 on 01/25/2016 revealed there were data collection information titled "Acute Clinical Outcomes indicators and Cultures, endotoxin, and AAMI". Section 1 titled data Collections included a number of indicator of clinical care. The compliance is recorded as a percentage. The packet dated July 7, 2016 had a sign in record that included both dialysis contract staff and hospital staff attended. There was no indication the Medical Director was included. There were no minutes for the meeting except for hand written notes. There were no indication of actions taken or follow up. Staff #4 confirmed this was the only meeting that she had with evidence of a joint meeting between the dialysis contractor and the hospital.

Based on review of records, observation,, and interview Nursing Services under the direction of the Chief Nursing Officer failed to:

A. ensure all Nursing Directors had current and correct job descriptions and evaluations in their personnel records. In addition they failed to ensure the daily operation of the dialysis was assigned to a hospital member and that clear lines of authority and responsibility were developed. These deficient practices had the likelihood to cause harm to all patients receiving care at the facility by failure to ensure the management staff were informed of their area of responsibility and evaluated using a job description reflecting their area of responsibility. Citing 2 (#22 and # 39) of 2 (#22 and #39) nursing management personnel records reviewed.

See Tag A0386



B. reassess psychiatric patients at the required intervals to ensure patient safety and stability of psychiatric condition in 4 out of 4 patients reviewed (Patient #s 1, 28, 29, 30).

See Tag A0396



C. safely administer medication according to hospital policy in 6 (Patient #s 44, 62, 63, 66, 67, and 68) of 8 (Patient #s 44, 62, 63, 64, 65, 66, 67, and 68) patients reviewed.

See Tag A0405



D. follow its own policy and procedure of blood administration and failed to;

a.) have completed blood consents and transfusion records in 2(#18 and 71) out of 4 (18, 71, 72, and 73) charts reviewed.

b.) have a physician order for a rate of transfusion in 3 (#71, 71, and 73) out of 4 (18, 71, 72, and 73) charts reviewed.

c.) have an order to transfuse blood in 1 (#73) out of 4 (18, 71, 72, and 73) charts reviewed.

d.) have an accurate process to determine if the person that picked up the blood from the lab, was the RN checking it with another nurse at the bedside before administration in 4 (#18, 71, 72, and 73) of 4 charts reviewed.

e.) document delays in blood administration in 2 (#71 and 73) of 4 (18, 71, 72, and 73) charts reviewed.



See Tag A0409

Based on record review and interview, the Chief Nursing Officer failed to ensure all Nursing Directors had current and correct job descriptions and evaluations in their personnel records. In addition they failed to ensure the daily operation of the dialysis was assigned to a hospital member and that clear lines of authority and responsibility were developed. These deficient practices had the likelihood to cause harm to all patients receiving care at the facility by failure to ensure the management staff were informed of their area of responsibility and evaluated using a job description reflecting their area of responsibility. Citing 2 (#22 and # 39) of 2 (#22 and #39) nursing management personnel records reviewed.

Findings:

In an interview with staff #22 on January 26, 2016 at 10:30 a.m., she stated that she and staff #39 were assigned as co-directors of the dialysis unit. Staff #22 stated they were responsible for the patient care based on the unit the patient was assigned to. She stated she was the Director of the Medical Unit and staff #39 was Director of the Intensive Care Unit. She stated that if the patient was on the medical unit she was responsible and if the patient was in the intensive care unit staff #39 was responsible. When asked who was responsible for the overall operation including the water and technical system, Staff #22 stated she did not know. She stated she "guessed they would split the responsibility based on the unit the patient was being treated in. An interview with staff #39 on January 26, 2016 at 10:45 a.m. confirmed that she was responsible for the dialysis unit if the patient was in the intensive care unit. She stated she agreed with the statements made by staff #22. Staff #39 did not know who was responsible for the technical parts of the dialysis unit.

Review of Staff #22 personnel record revealed her last annual evaluation was completed on July 13, 2016 by Staff #1. The annual employee performance appraisal dated July 13, 2016 indicated she was the "Director of Cardiopulmonary Department" Staff # 22 confirmed she was evaluated using that job title criteria. Staff # 22 confirmed that she was not the "Director of the Cardiopulmonary Department and that Staff #1 had completed the evaluation on the wrong form. Staff #22 confirmed she had signed the evaluation on July 13, 2016. Staff #22 agreed that there was nothing in her personnel file that outlined her responsibilities for the dialysis unit.

Review of Staff #39 personnel record revealed her last annual evaluation was completed on July 13, 2016 by Staff #1. The annual employee performance appraisal dated July 13, 2016 indicated she was the "Director of Quality" Staff #39 confirmed she was evaluated using that job title criteria. Staff #39 confirmed that she was not the "Director of Quality" and that Staff #1 had completed the evaluation on the wrong form. Staff #39 confirmed she had signed the evaluation on July 13, 2016. Staff #39 agreed that there was nothing in her personnel file that outlined her responsibilities for the dialysis unit.

Review of the hospital organization chart revealed the dialysis unit was not on the current organizational chart.

Based on review of records and interview, Emergency Department (ED) nursing staff failed to reassess psychiatric patients at the required intervals to ensure patient safety and stability of psychiatric condition in 4 out of 4 patients reviewed (Patient #s 1, 28, 29, 30).

Findings were as follows:

On 1-25-2017 a tour of the ED and interview was completed with Staff #18. Staff #18 stated the frequency of vital signs and reassessment is determined by the acuity assigned at the triage assessment. Staff #18 stated that a separate monitoring sheet is not required for psychiatric patients who are being evaluated or are waiting on placement. Staff #18 stated they do not always assign a sitter to psychiatric patients and, at times, will allow the family to sit with patient to ensure patient safety.

Review of the Palestine Regional Medical Center policy titled "Assessment Organization Wide", PolicyStat ID: 2312565, last revised 5-2016, expiration 5-2019 was as follows:

Page 9, Nursing Services, Section 2. Emergency Department, Item 2. "The triage RN will categorize patients as they present for triage as follows:
a. Level I
1. Initial assessment - The patient's condition may or does require immediate life saving (sic) medical intervention. The patient is very briefly evaluated by the triage nurse and immediately sent to the treatment room.
2. Vital signs are obtained every 5-15 minutes until stable then hourly.

...
b. Level II
1. Initial assessment - The patient's condition is potentially unstable. The patient should receive physician assessment as soon as possible.
2. Vital signs are obtained every 15-30 minutes until stable then every 2 hours.
3. Patient is reassessed at every hour until stable, then every 2 hours.

...
c. Level III
1. Initial assessment - The patient's condition is stable and no obvious distress noted.
2. Vital signs on admission. Reassess any abnormal vital signs every 2 hours. Reassess stable vital signs every 4 hours.
3. Patient's condition will be reassessed every 4 hours.

Review of Palestine Regional Medical Center policy titled "Standards of Practice and Care", PolicyStat ID: 1009165, last revised 11/2004, expiration 08/2017 was as follows:

Page 5, "Fundamental Emergency Department nursing interventions include, but are not limited to the following:

Priority 1 (Critical Care) - Initial assessment and reassessment (to include vital signs) documented every 15 minutes (more frequently if warranted by patient's condition).

Priority 2 (Emergent) - Initial assessment and reassessment (to include vital signs) documented every 15-30 minutes (more frequently if warranted).

Priority 3 (Urgent) - Initial assessment and reassessment (to include vital signs) documented every 30-60 minutes (more frequently if warranted).

Priority 4 (Non-Urgent) and Priority 5 (Routine care) - Initial assessment and reassessment (to include vital signs) documented every one hour (more frequently if warranted).

Vital signs will be repeated if not within normal limits, as follows:
Adult ranges:
Temp: 96.4 - 99.1 degrees F
BP: 95/60 -140/90 mm/Hg
Pulse: 60 - 80 bpm
RR: 12 - 24 / min"


Review of Palestine Regional Medical Center Policy titled "Suicide Risk Assessment and Suicide Precautions", PolicyStat ID: 2047947, last revised 01/2016, expiration 01/2019 was as follows:

Page 9, INTERVENTIONS, E. "An appropriate level of observation and monitoring shall be implemented. Regardless of the level of observation utilized for patients with suicidal risk, the patient's status (including mood, behavior, and location) must be documented at least every 15 minutes.

F. Reassessment of suicidal ideation and intent will be reassessed and documented at least every four hours.

Review of Patient #1's chart revealed the patient was a 21 year old female who was triaged on 1/23/2017 at 5:31 P.M. as and acuity level 3, Urgent. Her presenting complaint was that she was hearing voices and having suicidal thoughts for the past 3 days. Her husband had stopped her from taking pill, drowning self, and cutting self. The patient was transferred to another location by the sheriff's department on 1/24/2017 at 1:16 A.M. Patient #1 was in the ED care for 7 hours and 45 minutes.

Patient #1 had vital signs documented twice; once at 5:36 P.M. and once at 1:14 A.M. No nursing record was found documenting the patient status every 15 minutes or reassessing her suicidal ideation and intent.


Review of Patient #28's chart revealed the patient was a 25 year old male who was triaged on 1/23/2017 at 3:13 P.M. as and acuity level 2, Emergent. His presenting complaint was that he was "released from jail today after months in custody pt states has not been on his meds is hearing voices depressed and has anxiety issues pt denies suicidal or homicidal ideations." (sic) Patient #28 was transferred to another location by the sheriff's department on 1/24/2017 at 1:18 A.M. Patient #28 was in the ED care for 10 hours and 5 minutes.

Patient #28 had vital signs documented twice; once at 3:16 P.M. and once at 1:16 A.M. No nursing documentation of care, assessment, or reassessment was found between 3:58 P.M. when a urine drug screen was sent to the lab and the discharge assessment at 1:16 A.M the next morning (over 11 hours).


Review of Patient #29's chart revealed the patient was a 63 year old female who was triaged on 1/2/2017 at 9:52 A.M. as and acuity level 2, Emergent. Her presenting complaint was that "Spouse states: she has been hearing voices for 2 month patient states she doesn't want to stay here again those nurses down there are mean to me voices are telling me to pack up and leave, she packed up all her stuff on sat and put it on the porch" (sic) Patient #29 was admitted on 1/2/2017 at 2:29 P.M. Patient #29 was in the ED care for 4 hours and 37 minutes.

Patient #29 had vital signs documented twice; once at 9:58 A.M. and once at 2:23 P.M. (4 hours and 25 minutes)


Review of Patient #30's chart revealed the patient was a 24 year old female who was triaged on 1/17/2017 at 10:22 P.M. as and acuity level 3, Urgent. Her presenting complaint was that she was "very depressed and suicidal, on medication, Access will not see her until her appointment." The patient was admitted on 1/18/2017 at 3:22 A.M. Patient #30 was in the ED care for 5 hours.

Patient #30 had vital signs documented three times; once at 10:32 P.M. with an abnormal pulse of 121 beats per minute; once at 2:43 A.M.; and a third time at 3:20 A.M. No nursing record was found documenting the patient status every 15 minutes or reassessing her suicidal ideation and intent.

Based on observation, interview and review of documents, nursing staff failed to safely administer medication according to hospital policy in 6 (Patient #s 44, 62, 63, 66, 67, and 68) of 8 (Patient #s 44, 62, 63, 64, 65, 66, 67, and 68) patients reviewed.

This deficient practice could result in serious harm to all patients.

Findings are as follows:

On 1-25-2017 at approximately 4:00 P.M., a tour of the Intensive Care Unit was made with Staff #39. Upon reviewing Patient #63's chart on the computer, it was found that two medications had not been given as ordered. Buspar (an antidepressant) was scheduled at 1:00 P.M. and Neurontin (given for seizures or nerve pain) was scheduled at 2:00 P.M. Staff #53 was identified as the nurse caring for the patient. When interviewed, Staff #53 stated he had been busy during those times and hadn't given it, but would give it now.

On 1-26-2017 at approximately 10:15, a tour of the Medical/Surgical Unit medication room was made with Staff #22. A small paper cup was observed to contain 10 pills and was located in a plastic bin with room #328 on it. Staff #22 stated Staff #54 was the nurse caring for that patient. Interview with Staff #54 was conducted. First Staff #54 stated Patient #62 was asleep, so medications could not be given. Staff #54 stated he put the medication back in the medication room to give later. Staff #54 was asked to identify the medication to be given since none of it was marked. Staff #54 was not able to identify the medication in the cup on sight. Staff #54 had a medication list and stated he had not given Norvasc (for blood pressure), Lotensin (for blood pressure), Aspirin (blood thinner), Aricept (for dementia), Vitamin B-6 (supplement), Vitamin B-12 (supplement). It was noted on the Medication worklist that Patient #62 had 4 other medications due at 9:00 A.M. along with the medications not given. One was to be given intravenous (IV - in the vein). One was an injection through the skin. The other two were pills to be given by mouth. Staff #54 was asked how those medications were given when the others had not been given. Staff #54 the patient wasn't asleep, but drowsy. After giving the first 4 medications, he decided to hold the rest until later.

An interview was conducted with Staff #22. Staff #22 confirmed that Staff #54 had documented in the patient record that all medications had been given, including the medication found in the medication room. Staff #22 stated that medication opened at the bedside and not given is supposed to be wasted, not brought back into the medication room for dispensing at another time. Staff #22 confirmed that medication opened and out of the package should be labeled with the medication, dosage, and patient information. Staff #22 confirmed that Staff #54 had not followed procedures for safe medication administration.

Review of Patient #44's Medication Administration Record (MAR) revealed that on 1-25-2017, 4 medications were scheduled to be given at 9:00 A.M. but were given at 09:38 A.M. or later. Two medications scheduled for 9:00 P.M. were given at 7:50 P.M. and 8:00 P.M. No reason for early or late administration was found documented.

Review of Patient #66's MAR showed that Xarelto was scheduled to be given on 1-25-2017 at 5:30 P.M., but was administered at 4:56 P.M. No reason for early administration was found documented.

Review of Patient #67's MAR showed that Coumadin was scheduled to be given on 1-20 at 5:00 P.M. but was given at 4:17 P.M. On 1-23-2017, Coumadin was scheduled for 5:00 P.M. but was given at 5:42 P.M. No reason for early or late administration was found documented.

Review of Patient #68's MAR showed that Pepcid and Lovenox were scheduled to be given on 1-21-2017 at 9:00 A.M. but was given at 8:25 A.M. No reason for early administration was found documented.

Review of Palestine Regional Medical Center policy titled "Medication Administration Guidelines", last revised 04/2015 and expires 04/2018 was as follows:

"PROCEDURE

A. MEDICATIONS:

...

12. Medications are to be administered 30 minutes before or after designated time of administration

13. The following standardized times are used for medication administration only allowing for ½ hour before and after the time scheduled:

....

B. PATIENT SAFETY
3. Never give medication from an unmarked or poorly marked container.

...

19. The e-MAR (electronic Medication Administration Record) be first viewed. Then the Medication barcode and e-MAR (electronic Medication Administration Record) will be scanned using the Medhost HMS scanning system. Unit doses medications will remain unopened until time of administration to the patient at the bedside.

...

L. DOCUMENTATION FOR MEDICATION ADMINISTRATION

...
2 Medications are to be documented in the e-MAR with the date and time of administration.

...
c. If the medication is given outside of the scheduled time frame, the nurse must document on the e-MAR the reason for variance."

Based on reviews and interviews the facility failed to follow its own policy and procedure of blood administration and failed to;

a.) have completed blood consents and transfusion records in 2(#18 and 71) out of 4 (18, 71, 72, and 73) charts reviewed.

b.) have a physician order for a rate of transfusion in 3 (#71, 71, and 73) out of 4 (18, 71, 72, and 73) charts reviewed.

c.) have an order to transfuse blood in 1 (#73) out of 4 (18, 71, 72, and 73) charts reviewed.

d.) have an accurate process to determine if the person that picked up the blood from the lab, was the RN checking it with another nurse at the bedside before administration in 4 (#18, 71, 72, and 73) of 4 charts reviewed.

e.) document delays in blood administration in 2 (#71 and 73) of 4 (18, 71, 72, and 73) charts reviewed.


Review of the facility's policy and procedure "Blood Transfusions" Stated, 5.) There must be an informed consent for blood transfusion in the patient's medical record."

Review of the blood consents revealed the patient signed a consent that was not completed for the following patient;
Review of patient #71's chart revealed the consent had a blank for the physician's name, what product they were consenting to, and alternatives to treatment.

Review of the facility's policy and procedure "Blood Transfusions" Stated, "1. Blood transfusions, and /or blood products, i.e...FFP, platelets, must be ordered by the physician. *****The physician must order a rate of transfusion. *****"

Review of the patient charts revealed the following patients did not have an ordered rate for transfusion;
1. Patient #71
a.) 12/14/16 19:00 (7:00PM) Transfuse 2 units of PRBC's
b.) 12/14/16 at 18:27 (6:27PM) RBC Unit Order #2200
c.) 12/14/16 at 18:27 (6:27PM) RBC Unit Order #2300

2.) Patient #72
a.) 1/21/17 at 17:50 (5:50PM) Transfuse 1 unit of PRBC
b.) 1/23/17 at 9:29AM Transfuse 1 unit of PRBC

3.) Patient #73
a.) 1/16/17 at 10:31AM Transfuse 1 unit of PRBC



Review of the facility's policy and procedure "Blood Transfusions" Stated," 3. Blood Transfusions and /or products must be retrieved from lab, signed for and witnessed by two people before leaving the lab, have two licensed staff co-sign (one must be RN starting transfusion) as part of the patient identifier process at the bedside, started and monitored for the first 15 minutes by an RN." Blood units removed from the Laboratory may not be returned if it is out of the Laboratory Blood bank for more than 15 minutes, or if the seal is broken.

Review of the following patient charts #18, #71, #72, and #73 revealed there was no documentation in the patient charts on who picked up the blood from the lab and at what time.

Review of the Laboratory "Blood Bank Worksheet" revealed a section where the blood is retrieved from the lab. In the unit disposition section is a place for the date and time, if the unit was visually "ok", who it was issued to, and issued by.

The log revealed patient #71's blood was ready to be picked up on 12/14/16 at 19:52 (7:52PM). The log revealed the blood was not picked up from the lab until 2234 (10:34PM) a 2 ½ hour delay. The issued to and issued by was just initials. The initials were difficult to read and there was no authentication on the log to match the initials with the signature. Some of the dates and times on the log had been marked over and were not legible.

Review of patient #72's blood bank worksheet log revealed the blood was picked up in the lab on 1-21-17 at 2254 ( 10:54PM). There was just initials with no name or title verification on the log. Another unit was picked up on 1-23-17 at 1331 (1:31PM). The log revealed the initials "ok" on the issued to line. There is no nurse administering the blood with initials OK.

Review of patient 73's chart revealed blood was picked up in the lab on 1-16-17 at 1358 (1:58PM) and another unit on 1-17-17 at 0000 (12:00AM). There was only initials with no name or title verification on the log.

There was no way to accurately determine, if the person that picked up the blood from the lab, was the RN checking it with another nurse at the bedside before administration. There was no found documentation for the delay in blood administration.


Review of the Dialysis charts revealed the blood administration was done on a paper copy and not in the electronic record. The paper transfusion record for patient #18 was found to be incomplete.
Review of the paper blood record revealed the "issued date and time" from the lab was blank.
Review of patient #18's blood record under transfusion record section revealed on 9/28/16 blood was started at 10:45AM and the "Date/Time stopped was blank. Under the vital signs section revealed the blood was started at 2245 (10:45PM) and ended on 23:15 (11:15PM). The Medical History Report section was blank and required a physician/nurse signature.

Review of the second blood unit, under the transfusion record section, revealed there was not two people checking the blood at the bedside. The signature line for the transfusionist was blank. The date/time section was blank. Under the vital signs section the blood was shown started at 23:15 (11:15PM) and stopped at 20:45PM (8:45PM). Three hours before it was started. The Medical History Report section was blank and required a physician/nurse signature.

Review of Patient 73's chart revealed there was an order written on 1/16/17 at 8:22AM for a unit of RBC (blood). The priority on the order stated, "Stat" (now). There was no order found to transfuse the blood. Review of the blood blank log revealed that someone came and got the blood (initials illegible) on 1/16/17 at 1358(1:58PM); 5 ½ hours later. The Blood Administration Nurses Notes dated 1/16/17 revealed the blood was started on 1/16/17 at 1430 (2:30PM); 6 hours and 8 minutes after it was ordered. There was no documentation found on why the "stat" order was delayed. The blood was documented as completed at 1/16/17 at 1700 (5:00PM).

Review of patient #73's physician orders revealed the RBC unit was ordered ASAP on 1/16/17 at 10:31. An order was found that stated 1/16/17 at 10:31AM "Transfuse 1 unit or PRBC routine." According to the policy and procedure "Blood Transfusions" the time frame for administration of ordered blood is:
"Stat: 15 minutes after notification that it is ready.
ASAP: 30 minutes after notification that it is ready.
Routine: 2 hours after notification that it is ready."

Review of patient 73's blood administration record revealed the blood was not started until 1/17/16 at 00:12 (12:12AM) 13 hours and 42 minutes later. There was no documentation found on why the blood administration was delayed.

An interview with staff #22 was conducted on 1/25/17. Staff #22 confirmed the above findings. Staff #22 stated, "There is no proof that the nurse picked up the blood in the chart. The only place it's documented is in the lab and I see its just initials."

Based on interview, observation and document review, the facility failed to

A. 1. ensure complete medical records were forwarded when patient's were transferred to a higher level of care for 3.5 months, October of 2016 through mid January 2017
2. ensure complete patient medical records were obtained prior to shredding hand written documents that were scanned into the patient permanent medical record in 3 (#38, #40, #42) of 6 (#38, #39, #40, #41, #42, and #43) patient medical records reviewed
3. demonstrate current quality improvement goals for the department for 2 years (January 2015 to January 2017)

Refer to Tag 0432


B. protect records that contained patient specific Protected Health Information (PHI) on 1 unit (Medical - 3C) out of 3 units (Medical - 3C, Intensive Care Unit, and Emergency Department) toured.

Refer to Tag 0441


C. ensure the medical record was legible. Citing 8 months (June 2016, July 2016, August 2016, September 2016, October 2016, November 2016, December 2016 and January 1, 2017-January 20, 2017) of 8 months of water logs and chlorine logs reviewed. In addition the serial number was not written on each individual page of the log to indicate which Reverse Osmosis (RO) the checks were for, should the paper be removed from the notebook for RO # RO26180.

Refer to Taqg 0450


D. ensure the patient's medical record contained a signed consent for treatment and services for 3 (#38, #40, and #42) of 6 rehab patients (#38, #39, #40, #41, #42, and #43).


Refer to Tag 0466

Based on interview and document review the hospitals Health Information Management Department failed to

A) ensure complete medical records were forwarded when patient's were transferred to a higher level of care for 3.5 months, October of 2016 through mid January 2017,

B) failed to ensure complete patient medical records were obtained prior to shredding hand written documents that were scanned into the patient permanent medical record in 3 (#38, #40, #42) of 6 (#38, #39, #40, #41, #42, and #43) patient medical records reviewed and

C) failed to demonstrate current quality improvement goals for the department for 2 years (January 2015 to January 2017)



This deficient practice had the likelihood to effect all patients of the hospital.



Findings included:

A.
On 1/24/2017 in the morning, the Director of the Health Information Management (HIM)Department was interviewed, regarding how patient medical records were sent to a receiving hospital when a patient must be transferred to that hospital for a higher level of care or once transferred, a request for the patient's medical record was requested?

The director indicated the hospital's electronic medical record would be copied and sent via fax to the receiving hospital.

Upon further questioning the director of HIM confirmed the hospital had two distinct electronic medical records collection system in use. The Emergency Department used a system that did not interface with the hospitals primary electronic system.

When asked if both systems submitted their electronic record to be forwarded to the hospital of higher acuity on behalf of the patient, she replied "no". She indicated she did not send the Emergency Department medical record because she had immediate access only to the hospitals main medical record system.

When ask why she would not include the Emergency Departments medical record she asked, "wouldn't that fall under the 30 days to complete rule?"

A request was made to review the policy for transmittal of medical records. No policy was provided, however the Director indicated, they didn't have a policy that required the inclusion of the Emergency Department medical record be sent with the patient when the patient was being transferred to a higher level of acuity.

The HIM department failed to compile and send a complete patient medical record upon request of the receiving hospital or when the patient was transferred to a hospital for a higher level of care.



B.
On 1/26/2017 in the conference room the medical record for Rehab patient's #38 through #43 were reviewed. No consent for admission and treatment to the rehab department was found in the electronic medical record for patient #38, #40 and #42.

An interview with the Director of the Rehab unit, who assisted with the electronic record review, indicated the consents were manually scanned in and if they did not show up in the electronic record they might still be in the Health Information Management department waiting to be scanned. She volunteered to retrieve the consents from the HIM department.

The Rehab Director returned to say there were no documents found in the HIM department that had not been scanned. Scanned documents had already been shredded.

On 1/26/2017 a review of the HIM policy #2543743, "Post Imaging Medical Records Management, Retention and Destruction". Found below the title "POLICY". Paragraph three.

"Once scanned into the hospitals scanning system, the paper version of the medical records will be maintained for 30 calendar days (POST SCANNED DATE, NOT DISCHARGED DATE). Upon expiration of this 30 day time frame, the scanned paper medical records will be eligible for destruction. Records will be destroyed in accordance with Section 111 EC .010. Page two: "Prior to commencing with record destruction the hospital Ethics Compliance Committee will acknowledge the commencement through documentation on the committee meeting minutes."

The HIM department did not maintain a log of when paper documents were scanned or what paper documents were scanned. When asked for the documents the staff replied, "they have already been shredded".

There was no way to determine if the completion of the form granting consent to treat for patient's #38, #40 and #42 had been omitted upon admission to the Rehab Unit or shredded upon discharge from the unit. Patient's #38, #40 and #42 had an incomplete medical record.



C.
On 1/24/2017 in the morning, an interview with the Director of the Health Information Management department revealed as a department they had followed the same Assessment and process Improvement goal "For years". When asked why, the director replied, "No one's asked me to change".

When asked if she felt there were areas within her department that could be improved she replied, "I don't want to sound arrogant but we have a perfect department, we perform perfectly and get along with the other departments. I don't know what we would improve on".

The manager was asked if the department worked on anything. She said they did chart audits and presented a tool titled "Medical Record Review Summary Sheet YEAR 2016". The tool allowed for 8 charts to be reviewed and the following indicators were listed:

"Medical History and Physical (H&P) Including:
Chief Complaint
Details of Present Illness
Relevant past, social & family history
Inventory of body systems
Impression
Plan
Documented within 24 hours
H&P update prior to surgery
Progress notes made by the medical staff and other authorized staff
Discharge summary to include:
Final Diagnosis
Discharge instructions
Post-operative progress notes:
All elements completed
Consult order/report available"

The above list is the physician's responsibilities when documenting in a patient's medical record.





The department was not auditing charts for patient rights violations such as failure to explain and obtain consent to treat, acknowledgment of the Patient's Rights and Responsibilities, the Grievance or Complaint information. The department was not auditing the charts for privacy violations. The department failed to reconcile policy with procedure when shredding scanned patient records. The department was not conducting any assessment or improvement objective that would improve the care of the patient during their stay or improve the method in which staff obtained information on the patient or maintained the information afterward.

Based on observation, interview and review of documents, the facility failed to protect records that contained patient specific Protected Health Information (PHI) on 1 unit (Medical - 3C) out of 3 units (Medical - 3C, Intensive Care Unit, and Emergency Department) toured.

On 1-26-2017, a tour of Medical - 3C Unit was conducted with Staff #22. At the Patient Care Tech (PCT) station on the "odd hallway" was a clipboard laying upside down. No staff were in the patient hallway. The clipboard was turned over and found to contain forms with patient specific PHI. The forms included:

Vital Signs Flow Sheet: Room Number; Nurse; Temperature; Pulse; Respirations; Blood Pressure; Oxygen Saturation Level. The form had Staff #50's name at the bottom with the date of 1-26-17 and time of "8:00"

This form was stapled to "Monitor Daily Treatment Sheet". This form also had Staff #50's name on it. It contained: Room Number; Patient's Name; Sex; Age; Length of Stay; Doctor; Diagnosis, Diet, and Comments. The Comments section allowed for handwritten comments. These comments included level of monitoring, if the patient had intravenous access (IV), if the patient were on oxygen, if the patient were on fluid restriction and how much fluid they could have, if they were on isolation precautions and type of precautions, and mental status (confused).

Interview was conducted with Staff #22. Staff #22 stated the clipboard belonged to the PCT. The PCT was not in sight. Staff #22 confirmed that anyone entering the hallway, such as patients and family member would have access to the clipboard. Staff #22 stated that PCT's have been instructed not to leave the clipboard in the open.

Review of the 1-26-2017 Staffing Schedule for Medical - 3C confirmed that the only PCT working was Staff #50.

Based on record review and interview the facility staff failed to ensure the medical record was legible. Citing 8 months (June 2016, July 2016, August 2016, September 2016, October 2016, November 2016, December 2016 and January 1, 2017-January 20, 2017) of 8 months of water logs and chlorine logs reviewed. In addition the serial number was not written on each individual page of the log to indicate which Reverse Osmosis (RO) the checks were for, should the paper be removed from the notebook for RO # RO26180.


Findings:

Review of the facility policy titled "Correcting An Entry of a paper The Medical Record". (sic) "A. If a correction is needed while in the process of documenting the record, a single line should be drawn through the mistake with the correction above along with thee person making the corrections." (sic)

Review of the chlorine logs, water logs and medical records for June 2016, July 2016, August 2016, September 2016, October 2016, November 2016, December 2016 and January 1, 2017-January 20, 2017, revealed numerous write over of times and numbers. Some of the numbers were obliterated and the number could not be read. The individual pages of the logs did not have a serial numbers recorded on the logs for this RO. In an interview with staff #25 he stated the forms are always kept in the binder which had the RO serial number written on the binder. On January 24, 2017 at 0900 while observing in the dialysis unit there was a form with chlorine checks recorded without the serial number of the RO. The form was lying on a table and was not in a binder. Staff #24 confirmed it did not have an RO serial number recorded on it and stated she removed it from the binder to chart on.

An interview with staff # 4 on 01/24/2017 at 11:30 confirmed the findings in the logs. Staff#4 confirmed the hospital policy requires the staff to follow the above medical record policy.

Based on record review and interview the facility failed to ensure the patient's medical record contained a signed consent for treatment and services for 3 (#38, #40, and #42) of 6 rehab patients (#38, #39, #40, #41, #42, and #43).


This deficient practice had the likelihood to effect all patients of the hospital.


On 1/26/2017 in the conference room the medical record for patient's #38 through #43 were reviewed. No consent for admission and treatment to the rehab department was found in the medical record for patient #38, #40 and #42.

An interview with the Director of the Rehab unit assisted with the electronic record review and indicated the consents were manually scanned in and if they did not show up in the electronic record they might still be in the Health Information Management department waiting to be scanned. She volunteered to retrieve the consents not yet scanned.

The Rehab Director returned to say there were no documents found in the HIM department that had not been scanned. Scanned documents had already been shredded.

On 1/26/2017 a review of the HIM policy #2543743, "Post Imaging Medical Records Management, Retention and Destruction". Found below the title "POLICY". Paragraph three.

Once scanned into the hospitals scanning system, the paper version of the medical records will be maintained for 30 calendar days (POST SCANNED DATE, NOT DISCHARGED DATE). Upon expiration of this 30 day timeframe, the scanned paper medical records will be eligible for destruction. Records will be destroyed in accordance with Section 111 EC .010. Page two: (Prior to commencing with record destruction the hospital Ethics Compliance Committee will acknowledge the commencement through documentation on the committee meeting minutes.)

The HIM department did not maintain a log of when paper documents were scanned or what paper document was scanned. When asked for the documents the staff replied, "they have already been shredded".

There was no way to determine if the completion of the form granting consent to treat for patient's #38, #40 and #42 had been omitted upon admission to the Rehab Unit or shredded upon discharge from the unit by the HIM department, prior to scanning for retention. Patient's #38, #40 and #42 had an incomplete medical record.

Based on review of records and interview, the facility failed to establish an extended stay review process by billing method that includes how a patient would be identified as an extended stay outlier and how the Utilization Review (UR) Committee physicians would review the extended stay outliers for patients admitted to 3 out of 3 areas [Hospital (including the psychiatric unit of the hospital), Inpatient Rehab Services, and Geriatric Psych Services]. The Utilization Review Committee failed to review extended stay outlier cases for 3 of the 3 months reviewed.

Findings were as follows:

Review of the Palestine Regional Medical Center 2016 Utilization Management Plan was conducted.

Per the plan on page 2:
"Case Manager/Reviewer: The Case Manager/Reviewer (a registered nurse or other appropriately trained personnel) has the obligation to administer the Utilization Management Program and to facilitate the ongoing activities of the program.
The case manager/reviewer, under the direction of the Utilization Management Committee had the oversight responsibility for the following activities:

· Admission Review, to be performed within one working day following admission
· Continued Stay Review, to be performed concurrently within the time frame established by the payor (sic) source. No more than every 3 days should lapse between continued stay reviews for non-commercial payors (sic). "

No process for the extended stay review was found under this delineation of responsibility for the case manager/reviewer.

Per the plan on page 9:

"H. Extended Stay Review:
The UR Committee must review all cases reasonably assumed by the hospital to be outlier cases because of extended length of stay exceeds the threshold criteria for the diagnosis. The hospital is not required to review extended stay cases that do not exceed the outlier threshold.

· The UR committee shall review all cases reasonably assumed by the hospital to be outlier cases no later than 7 days after the 14th day. The UR Committee has determined that an outlier is any stay greater than 14 days for cost and length of stay.
· The case manager shall refer all outlier cases to a physician adviser for review and determination.
· The UR Committee shall review outlier data analysis through the physician advisor report."

Section H did not include criteria for units that are not paid under the prospective pay system (PPS). Section H provided for the case manager to have oversight; making case managers responsible for referring extended stay outlier cases.

Review of the patient Admission Register for July, August and September 2016 was conducted by Hospital Service type.

July patients with a length of stay (LOS) greater than 14 days were:
ICU (intensive care unit): One 17 day LOS
PSY (psychiatric unit): One 26 day LOS; one 20 day LOS; one 19 day LOS, one 18 day LOS; one 17 day LOS and two 15 day LOS
IRF (inpatient rehab facility): One 24 day LOS
GER (geriatric psych): One 15 day LOS

August patients with a LOS greater than 14 days were:
MIP (medical inpatient): One 21 day LOS and one 19 day LOS
IRF: One 19 day LOS and two 15 day LOS
GER: One 29 day LOS; one 27 day LOS; two 23 day LOS; one 20 day LOS; one 18 day LOS, one 17 day LOS, one 16 day LOS; and one 15 day LOS

September patients with a LOS greater than 14 days were:
MIP: One 30 day LOS and one 16 day LOS
IRF: One 21 day LOS and one 15 day LOS
GER: One 55 day LOS, one 18 day LOS, and two 15 day LOS

Review of the minutes of the Palestine Regional Medical Center Medical Records/Utilization Review Committee October 6, 2016 meeting minutes was conducted. Upon review of minutes, the medical records for the above cases were not presented for committee review. The minutes did not indicate that extended stay outliers were ever discussed or reviewed. A physician advisor report was not listed on the agenda for the meeting. Attachments did not include a physician advisor report or an extended stay outlier report.

Interview was conducted with Staff #19. Staff #19 confirmed that the 2016 Utilization Review Plan was in use. Staff #19 provided a draft of the 2017 Utilization Review Plan that had not been sent for approval of the Utilization Review Committee. Staff #19 was not able to define how an extended stay outlier was selected. When asked how charts for review were selected, Staff #19 stated, "Well, Radiology or Lab will submit charts if they suspect over-utilization. The Case Managers will submit charts if there is a problem with the stay." Staff #19 was not able to define what "a problem with the stay" meant.

Staff #3 was interviewed. Staff 3# stated the hospital bills both PPS and non PPS services. Staff #3 reviewed the 2016 Utilization Review Plan and confirmed it did not provide for review based on type of billing. Staff #3 confirmed the 2017 Utilization Review Plan had not been submitted to committee for approval.

Based on observation and interview, the facility failed to store supplies in a manner that ensured they would not be contaminated in 2 units (Intensive Care Unit [ICU] and Medical/Surgical units) out of 4 units observed.

Findings included:

On 1-25-2017 a tour of the ICU was completed with Staff #39. In the ICU the following supplies were observed to be stored where, if leaking, they would contaminate the supplies underneath or in the same bin with them:

Liquids stored over patient briefs, batteries stored over isolation gown and sterile supplies, liquids stored over patient plastic drinking cups, disinfecting wipes stored in bin with patient supplies. Findings were confirmed by Staff #39.

On 1-26-2017 a tour of the Medical/Surgical unit was completed with Staff #22. The following supplies were observed to be stored where, if leaking, they would contaminate the supplies underneath or in the same bin with them:

Batteries were stored over sequential compression sleeves used on patient legs to prevent blood clots, disinfecting wipes were stored with patient arm boards, and liquids were stored over patient supplies and sterile items. Findings were confirmed by Staff #22.

Interview with Staff #22 was completed. Staff #22 stated that the layout of the storage room was controlled by Materials Management. Interview with Staff #51 was completed. Staff #51 confirmed that Materials Management did control the layout to help with stocking and inventory control.

Based on record review and interview the facility failed to:

A. develop and implement policies governing prevention and control of communicable diseases, as required by the State of Texas, by having evidence of the staff Hepatitis B immunizations for all clinical staff; by having proof of their hepatitis B antibody conversion, non-responder status, or have administered the immunization. Citing 6 staff employee health files reviewed (#40, 42, 44, 45, 46, and #47) of #11 staff (#4, #22, #39, #40, #41, #42, #43, #44, #45, #46, and #47) employee health records reviewed.

B. ensure the staff conducted appropriate infection control measures, to prevent the spread of infections in the dialysis unit. Citing 4 (#35, #37, #46, and #47) of 5 (#35, #37, #38 #46, and #47) staff observed.
C. ensure the staff stored medication and linen in a clean area.

These deficient practices have the likelihood to cause harm to all patients receiving care in the hospital.

Findings:

A. Review of 25 TAC 1.701-1.704 revealed:

"1.701 Definitions:

1) Covered individual--
(A) an employee of the health care facility;
(B) an individual providing direct patient care under a contract with a health care facility; or
(C) an individual to whom a health care facility has granted privileges to provide direct patient care.
(2) Department-Department of State Health Services.
(3) Health care facility--
(A) a hospital licensed under the Health and Safety Code, Chapter 241;

1.702 Vaccine Preventable Diseases

(a) Each health care facility shall develop, implement, and enforce a policy and procedures to protect its patients from vaccine preventable diseases. (b) The policy must: (1) require covered individuals to receive vaccines for the vaccine preventable diseases specified by the facility based on the level of risk the individual presents to patients by the individual's routine and direct exposure to patients; (2) specify the vaccines a covered individual is required to receive based on the level of risk the individual presents to patients by the individual's routine and direct exposure to patients; (3) include procedures for verifying whether a covered individual has complied with the policy; (4) include procedures for a covered individual to be exempt from the required vaccines for the medical conditions identified as contraindications or precautions by the federal Centers for Disease Control and Prevention; (5) for a covered individual who is exempt from the required vaccines, include procedures the individual must follow to protect facility patients from exposure to disease, such as the use of protective medical equipment, such as gloves and masks, based on the level of risk the individual presents to patients by the individual's routine and direct exposure to patients; (6) prohibit discrimination or retaliatory action against a covered individual who is exempt from the required vaccines for the medical conditions identified as contraindications or precautions by the federal Centers for Disease Control and Prevention, except that required use of protective medical equipment, such as gloves and masks, may not be considered retaliatory action for purposes of this section; (7) require the health care facility to maintain a written or electronic record of each covered individual's compliance with or exemption from the policy; and (8) include disciplinary actions the health care facility is authorized to take against a covered individual who fails to comply with the policy. (c) The policy may include procedures for a covered individual to be exempt from the required vaccines based on reasons of conscience, including a religious belief. 1.704 Disciplinary Action A health care facility that violates this subchapter is subject to enforcement action by the department, including but not limited to imposition of administrative penalties, in the same manner, to the same extent, and pursuant to the same procedures, as if the health care facility had violated a provision of the applicable chapter of the Health and Safety Code or department rules as follows: (1) for hospitals, Health and Safety Code, Chapter 241, and 25 Texas Administrative Code (TAC), Chapter 133. " Review of " Administrative policy 16-12.1 Protect Patients From Exposure to Vaccine Preventable Diseases. Requires individuals be vaccinated for pertussis, hepatitis B and receive influenza vaccines yearly. The policy outline the required evidence and vaccination required for all preventable diseases expect Hepatitis B. The facility policy did not cover all immunization required by Texas State Law.
Review of employee health files for staff #40, 42, 44, 45, 46, and #47 revealed there was no evidence of Hepatitis B immunizations or evidence of Hepatitis B antibody conversion or non-responder status.

An interview with staff # 34 on 01/24/2017 at 2:30 p.m., confirmed the findings in the employee health records.

B. The facility policy: 7-03-09 (1.) "Hands will be washed upon entering the hospital/facility, prior to gloving, after removal of gloves, between patients, after contamination with blood or other infectious material, after patient and contaminated machine contact, between patients, before touching clean area such as counter tops, supply carts, or medication carts, and at the close of the business day prior to going home."
Observation in the dialysis unit on January 24, 2017 staff #35 was observed at 0900 a.m. charting on the paper medical record with the same gloves on that she had used to provide patient care.
On January 24, 2017 staff #24 was observed removing gloves and did not clean hands prior removing her yellow gown and touching other items in the unit such as the curtain. Staff # 24 was then observed using the stethoscope examining the patient. Staff # 24 then placed the stethoscope around her neck and was later observed returning the stethoscope to an area where it was hung up on the wall, without disinfecting the stethoscope.
Staff #24 was observed using a syringe to deaden the patient's access. She deadened the first access site, recapped the safety syringe and returned it to the area where she had the access needles lying. She then picked up the same syringe and deadened the second access without using a new needle and syringe. She also prepped the access and introduced the access needles with the same gloves. She failed to change gloves and disinfect hands prior to performing the final access of the patient dialysis site.
Interview with Staff #22 on January 24, 2017 at 09:30 a.m. confirmed these were not appropriate infection control techniques and that the staff failed to follow the facility's policy.
C. During a tour of the dialysis unit the medication was observed to be stored on the same shelf with notebooks and other items. The linens was observed to be stored in the same cabinet with containers of vinegar.
An interview with staff #22 on January 24, 2017 at 09:30 a.m. confirmed the above findings.




28659

D. demonstrate a process and policy for safe sanitation and storage of sonogram probes for 3 months (October, November and December) of 2016.


This deficient practice had the likelihood to effect all patients of the radiology department who under went trans-vaginal sonography.


Findings included:

On 1/24/2017 during a tour of the radiology department the director of the department confirmed the department provided ultra sound imaging, both external and trans-vaginal ultra sound imaging.

During the tour of the ultra sound room, two (2) sanitized trans-vaginal ultra sound probes were observe stored in plastic bags inside a drawer.


Storage of sanitized probes in plastic bags contributes to moisture build up and the potential for mold, and bacterial growth on the probe.


Review of the "policy 3209151, page #2, item #10, Disinfected instruments should be used immediately or stored in a clean area to minimize contamination . Note: Cleaned instruments must be stored in a separate area away form CIDEX OPA Solution."

The policy failed to provide instruction on how to store the sanitized probe.


Further observation revealed the log for the use of the CIDEX OPA. The log included.
1. "Tray number", The word "Lot" was hand written over the word tray.
2. "Date Solution Activated" had the word TEMP hand written over it.
3. "Date Solution expires"
4. "Date Test strips expire"
5. "Test date"
6. "Test start time"
7. "Test end time"
8. "Test results (+) Pass/(-) Fail"
9. "Tested by"

Interview with the sonography staff #*** and #*** confirmed the above log was what they used to track the quality of the sanitation solution (CIDEX OPA).

The staff were asked to provide the original bottle the small amount of CIDEX OPA had be poured from. They produced a bottle with the date opened marked in black marker as 1/21/2017 and the expiration date 75 days later as 4/5/2017.

The staff confirmed that any tech who sanitized a probe would need to locate the original bottle, which was kept in a separate room, to know if the solution was within the 75 day window of safe use.

A review of the manufactures instruction for use of CIDEX OPA revealed the original bottle may be safely used to pour from for 75 days once the seal has been broken and the cap removed. Each time any amount of CIDEX OPA leaves the bottle for use, it is recommended for 14 days only. Each time during the 14 days the CIDEX OPA is used to sanitize an instrument, the solution must be checked for a temperature between 68-72 degrees.

Also when the instrument has completed the recommended soak time in the CIDEX OPA specific rinse times are required. Staff #13 indicated she swirled the probe in the "GUS" system rinse caddy for 30 seconds then rinsed the probe under running water for 1 minute. When asked how she measured the time, she said she just counted it off. The tech confirmed she did not use a timer and the log sheet did not track the time of the rinse.




36827


Based on observation and interview, the facility failed to maintain an environment that controlled the potential spread of infection in 3 units (Emergency Department [ED], Intensive Care Unit [ICU], and Medical / Surgical units) out of 4 units toured.

Findings were as follows:

A tour of the ED was completed on 1-24-2017 with Staff #18. The following conditions that could have caused the spread of infections were observed and confirmed during interview by Staff #18:

The flap cover to the linen cart had been propped open with pillow on top of it to keep it from closing and protecting the patient clean linen. Cleaning equipment for the patient areas were stored in the dirty utility room with trash and biohazard waste. Brooms, dust pans, and mops were stored next to a hopper (similar to a urinal that flushes, only larger) used to dispose of patient urine that had been collected for medical reasons. A plunger for unclogging backed up drains was stored next to a vacuum cleaner. The refrigerator in the patient nutrition area had been left ajar and the temperature had increased out of the safe range for foods stored inside. A partially empty bottle of drinking water and chemicals were on a shelf next to rolls of paper towels in a housekeeping closet.

A tour of the ICU was completed on 1-25-2017 with Staff #39. The following conditions that could have caused the spread of infections were observed and confirmed during interview by Staff #39:

An open package of cracker, candy, and staff drink were found in the housekeeping closet. A staff drinking cup and partially empty bottle of water were found in the patient nutrition room on the counter. A clean room, ICU-5 was observed to have trash and dirt on the mattress under the clean sheets; unknown substances stuck to the footboard of the bed; trash and dirt on the floor under the head of the bed, and worn wooden surfaced furniture that was porous and could absorb and retain bacteria. Office supplies (printer toner) were stored with patient medication and nutrition. During observation of patient care on 1-26-2017, Staff #52 was observed in an isolation room (ICU-3) to reach underneath her isolation gown with gloved hand to retrieve an alcohol wipe from her pocket. The patient was in droplet precaution isolation for influenza. Staff #52 was also taking care a patient in contact isolation in ICU-5.

A tour of the Medical/Surgical unit was completed on 1-26-2017 with Staff #22. The following conditions that could have caused the spread of infections were observed and confirmed during interview by Staff #22:

Linen in the clean linen storage area (1 bag of washcloths; loose sheets, pillow cases and washcloths) was found under the linen cart. In the medication room, a porous peg board with dried liquid stains was being used to hang patient medications from.

Based on observation, review of records, and interview, the cardiopulmonary director failed to:

A. ensure policies available for respiratory staff use were the most current policy for 14 of 14 policies reviewed.

B. provide respiratory medication information for respiratory staff use from a medically reliable source for 10 out of 10 medications reviewed.

Findings were as follows:

On 1-23-2017 a tour of the cardiopulmonary department and interview was completed with Staff #20. Staff #20 obtained a binder of respiratory policies from the staff work area in order to explain services provided. Staff #20 confirmed that this binder was at the station for all staff use.

Review of the binder revealed the following:

The front of the binder contained 3 signature sheets titled: "Policy and Procedure Guidelines Palestine Regional Medical Center Cardiopulmonary Department" They contained the statement, "Policy and Procedures reviewed and approved by the following:" and contained the Unit Manager Signature and Medical Director Signature. They were signed in 2009, 2011, and 2013.

The following policies were in the binder and were outdated:

Procedure Time Schedule - expired 01/2016
Pulse Oximeters, 3.6 - expired 01/2016
Metered Dose Inhalers, 3.7 - expired 01/2015
Aerosol Medication Therapy - expired 01/2016
Medication Distribution, 3.8a - expired 03/2015
Chesty Physiotherapy/ Postural Drainage/ CPT, 3.9 - expired 01/2015
Incentive Spirometry - IS - expired 01/2015
EPAP Therapy, 3.11A - expired 01-2015
Scope of Services - expired 01/2016
Respiratory Pharmacology Metaproterenol Sulfate - Date: 05-01-00 Reviewed 04/02
Respiratory Pharmacology Normal Saline - Date: 05-01-00 Reviewed 04/02
Respiratory Pharmacology Racemic Epinephrine - Date: 05-01-00 Reviewed 04/02
Respiratory Pharmacology Sterile Distilled Water, USP - Date: 05-01-00 Reviewed 04/02
Respiratory Pharmacology Terbutaline - Date: 05-01-00 Reviewed 04/02

The following medication information pages were found in the back of the binder for staff reference. These listed the generic name of commonly used respiratory medications and information about the medication, uses, and side effects. Nine (9) of 10 medication information pages were printed from Wikipedia, a free website that allows any user to upload and change information regardless of accuracy. All medication information pages indicated on the bottom right hand of the page that they were printed on 1/14/2011.

Tiotropium
Budesonide/formoterol
Levosalbutamol
Ipratropium
Dornase Alfa
Fluticasone/Salmeterol
Budesonide
Salbutamol
Acetylcysteine

The medication information page for Racemic Epinephrine could not be verified. The internet link (listed on the bottom of the page) to the information source, Virginia Commonwealth University, had been removed from the internet. This information page also indicated by date on the bottom right hand of the page that it had been printed on 1/14/2011.

Interview with Staff #3 was conducted. Staff #3 confirmed that current policies are on-line. Staff #3 stated that policy binders are no longer kept by departments and that department staff are to look up policies on-line.