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Based on interview and record review, the facility failed to document the provision of a list of patient ' s rights to patients in advance of furnishing patient care.

Failure to do so placed patients at risk of lack of ability to exercise these rights.

Findings:

Between 10/18/2016 at 11:50 AM and 10/19/2016 at 1:25 PM Surveyor #3 reviewed the medical records for five current patients. For two of the five patients (Patients #3, #5), no documentation was found that the patients had been given a list of their patient rights. Interview with the Director of Patient Care Support (Staff #1) on 10/20/2016 at 11:00 AM revealed that the registration staff were not consistent in documenting the giving of patient rights lists.

Based on interview and review of patient records, the facility failed to modify the patients ' plan of care when placing patients in restraints.

Failure to do so placed patients at neglect of meeting basic needs.

Findings:

On 10/19/2016 at 10:30 AM Surveyor #3 reviewed medical records, with the assistance of a Registered Nurse (Staff #2), for two patients (Patients #6, #7) who had been restrained. In review of the records, neither was found to have had a modification to their care plans when placed in restraints.

Based on interview and document review, the facility failed to document that the practitioners ordering restraints were given a working knowledge of hospital policy regarding the use of restraints.

Failure to do so placed patients at risk of harm related to being restrained.

Findings:

On 10/19/2016 at 10:30 AM Surveyor #3 reviewed medical records, with the assistance of a Registered Nurse (Staff #2), for two patients (Patients #6, #7) who had been restrained. The three physicians who had ordered the restraints were Staff Members #3, #4, #5. Staff #2 researched the training records of these physicians and reported to Surveyor #3 on 10/19/2016 at 1:45 PM that no record was found for training of the physicians.

Based on observation, interview, record review and review of facility policies and procedures the facility failed to implement their policy for a serious patient event for a patient (Patient #9).
Failure to investigate a report of a notifiable health condition of Legionnaires ' disease (a respiratory illness caused by legionella bacteria found in water systems) in a timely manner potentially placed other patients at risk for contracting legionnaire ' s disease when infection control measures are not implemented promptly.

Findings include:

1. The facility policy entitled " Serious Event Reporting " , revised 01/10/2016 read in part under " Scope: the scope of the policy includes active and discharged patients."
" Policy: the Serious Event Policy provides to achieve the highest level of response to a potential or actual serious event. Primary focus is to ensure that OMC (Overlake Medical Center) is doing everything possible to ensure the best possible outcomes for our patients. Serious events are always thoroughly investigated and responses to the investigation may include reporting to a regulatory agency, disclosing the event to patient/family, root cause analysis, review of information from the analysis, and developing and implementing a plan for process improvement " .

2. Patient #9 was seen in the facility emergency room on 9/23/2016 for facial injury. The patient was treated and released the same day. While in the emergency room the patient received some water with some pain medication.

3. Review of the infection control department ' s notes revealed the facility received a phone call from the local health department on 10/12/2016 about Patient #9 being urine antigen positive for legionnaire ' s disease while they were treated for a respiratory illness in another local emergency room.

4. The infection control department had documented on September 19, 2016 the facility had a confirmed case of legionella pneumophilla for Patient #8. At that time the facility began doing environmental testing on the units where Patient #8 had been receiving care to determine the source of the infection.
There was no documentation the infection control department did a thorough investigation of the report of Patient #9 being urine antigen positive for Legionella on 10/12/2016.

5. On 10/18/2016 at 11:00 AM, Staff #7 was interviewed by Surveyor #4. Staff #7 stated no testing of the emergency room water and ice machines was done at the time the report was received since the facility had received information from the local health department it could not be determined if Patient #9 got the infection from the community or while they were seen in the emergency room at the hospital.

6. On 10/18/2016 at 2:00 PM facility environmental staff was observed doing environmental testing in the emergency room.

Based on record review and interview, the hospital failed to ensure the patient ' s individualized plan of care was revised based on patient reassessment.
Failure to revise the patient ' s individualized plan of care, creates a risk for potential patient harm due to a lack of appropriate clinical interventions.
Findings:
1. The hospital ' s policy " Care Planning: Review, Documentation and Care Conference (32702, reviewed 1/5/16) " stated " ...a care plan is updated when there is a change in the patient condition " .
2. On 10/19/16 at 9:30am, Surveyor #1 toured the Intensive Care Unit with the Intensive Care Unit Nurse Manager (Staff #11). The medical record of Patient #11 was reviewed. According to the patient medical record, the patient had been mechanically ventilated for the past 48 hours, had been placing in soft wrist restraints, and was determined to be high risk for falls as per the nursing fall risk assessment. The patient was also in contact and droplet isolation precautions.
3. A review of the Patient #11 ' s medical record, revealed that the plan of care did not address the prevention of ventilator associated pneumonia, restraint use, patient high fall risk, and isolation interventions. These changes in the patient condition had occurred after admission and the initial plan of care was developed.
4. On 10/19/16 at 9:30am, in an interview with the Intensive Care Unit Nurse Manager (Staff #11) and the Staff RN (#18) it was confirmed the above problems were not present on the current plan of care.

ITEM #1


Based on observation and policy and procedure review, the hospital failed to ensure that staff properly performed hand hygiene.

Failure to perform hand hygiene when indicated places patients and staff at risk for infection.

Reference: Centers for Disease Control and Prevention, Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force, MMWR. 2002; 51 (No. RR-16). [pg. 32].

Findings:

1. The hospital policy titled, " Infection Control and Prevention Manual " (Rev 3/19/2012), states in part " A. Indications for Handwashing - Wash hands with either a nonantimicrobial soap or antimicrobial soap and water: 5. Following contact with a patient experiencing diarrhea or incontinence or possible contact with norovirus, Bacillus anthracis or Clostridial spores such as Clostridium difficile ...B. Decontaminate hands by performing hand rub or antiseptic handwash: 8. After removing gloves. "

2. On 10/19/2016 at 12:30 PM, Surveyor #2 observed a registered nurse (Staff #8) exiting a contact enteric precaution room (W424). S/he removed his/her personal protective equipment to answer a ringing phone in his/her pocket, but did not perform hand hygiene prior to grabbing the phone.


ITEM #2

Based on document review, observation and interview, the hospital failed to ensure bronchoscopes used in the Intensive Care unit were cleaned with an enzymatic detergent at the point of use.
Failure to ensure the bronchoscopes were cleaned with the enzymatic detergent at the point of care, created a risk of transmission of infectious disease to subsequent patients.
Findings:
1. The hospital ' s policy " Endoscopic Reprocessing (#13809, reviewed 1/11/2016) " stated " Point of Use Cleaning: 1. Pre-cleaning should be done prior to transporting the scope to the reprocessing area. Pre-cleaning should include wiping the exterior and suctioning the channels of the scope with an approved enzymatic detergent solution recommended by the scope manufacturer ..... "
2. On 10/19/16 at 9:30am, a tour was conducted of the Intensive Care Unit by Surveyor #1. A Respiratory Care Practitioner (Staff #13) was asked to demonstrate/describe the steps used in sending a bronchoscope after use to the Central Sterile Processing unit. S/He described wiping the outside of the scope and then placing the scope in a container for transport to Central Sterile Processing. S/he confirmed that there was no pre-cleaning with enzymatic detergent in the Intensive Care Unit prior to the scope being transported. This was confirmed by the Supervisor of Respiratory Care (Staff #12) and the Intensive Care Unit Nurse Manager (Staff #11).
3. On 10/19/16, at 2pm, with Surveyor #1, an interview with the Supervisor of Respiratory Care, Nurse Manager of the Special Procedures Unit, SPD manager, Infection Prevention Manager, and Director of Pharmacy, Respiratory Care, EEG, and Clinical Research was conducted. It was confirmed that the " Endoscope Reprocessing Policy " applied to all scopes used in the hospital. The interview also confirmed that the pre-cleaning with enzymatic detergent for bronchoscopes used in the Intensive Care Unit (at the point of use) was not a current practice.


ITEM #3

Based on record review, document review and interview, the hospital failed to follow its policy and procedure for oral care (chlorhexidine wash) in mechanically ventilated patients.
Failure to ensure mechanically ventilated patients received oral care with chlorhexidine mouth wash, created a risk of patients potentially developing ventilator associated pneumonia.
Findings:
1. The hospital ' s policy " Oral Care for Ventilated Patients-Respiratory Care (215301, reviewed 4/16/2015) stated " ET tube positions, tape change and oral care are normally performed q 8 hrs by Respiratory Therapy with Chlorhexidine " .
2. On 10/19/16 at 9:30am, Surveyor #1 toured the Intensive Care Unit with the Intensive Care Unit Nurse Manager (Staff #11). The medical record of Patient #11 was reviewed. The patient was mechanically ventilated for the past 48 hours.
3. On 10/19/16 at 9:30am an interview with the Intensive Care Unit Nurse Manager and Staff RN (#17) with Surveyor #1, confirmed oral care with chlorhexidine was performed every 12 hours on the patient, not every 8 hours as per the policy.


ITEM #4
Based on observation and interview, the hospital failed to ensure staff were protected from exposure to bio-hazardous contaminated instruments.
Failure to protect staff from exposure to contaminated instruments, created a risk of potential exposure to infectious diseases.
Findings:
1. On 10/19/16 at 9:30am, a tour was conducted of the Intensive Care Unit by Surveyor #1. In the dirty utility room, a bio-hazardous red bag containing a used intubation blade and stylet was observed. The red bag was in an open container ready to be sent to Central Sterile Processing. The end of the used stylet was protruding from the end of bag thus creating an exposure to a dirty instrument.
2. On 10/19/16 at 9:30am, this was confirmed by the Intensive Care Nurse Manager (Staff #11). The Intensive Care Nurse Manager stated that there were only two sizes of bio-hazardous bags available in the facility. These were the very large red bags and the smaller red bag observed by Surveyor #1.