The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

SAINT VINCENT MEDICAL CENTER 2131 W 3RD ST LOS ANGELES, CA 90057 June 16, 2017
VIOLATION: QAPI PERFORMANCE IMPROVEMENT PROJECTS Tag No: A0297
Based on interview and record review, the facility failed to ensure performance improvement projects were being conducted to reflect the scope and complexity of the services being offered at the hospital. This failed practice resulted in the potential for missed opportunities to improve the quality and safety of patient care throughout the organization.

Findings:

The Quality Care Committee Meeting minutes (the only minutes provided by the facility regarding QAPI) included reports from infection control, pharmacy, and medical staff departments were reviewed. There was no evidence of other clinical and non-clinical department managers or staff collecting, analyzing, or reporting data. There was no evidence of ongoing performance improvement projects being conducted in the facility.

On June 15, 2017, at 1:30 p.m., the survey team met with and interviewed the facility leadership team, including:

a. The Chief Nursing Officer (CNO);
b. The Chief Executive Officer (CEO);
c. The Quality Director (QD);
d. The Chief Medical Officer (CMO); and,
e. The Quality Nurse (QN 1).

During the interview, the QD stated there were currently no PI projects being conducted based on staff recommendations or suggestions, and there were no PI teams reporting to the Quality Care Committee.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, interview, and record review, the facility failed to ensure,

1. The outpatient clinics, to include the orthopedic, cardiac, orthopedic/spine, and joint clinics, provided each patient or their designated representative with their rights prior to providing care;

2 a. The initial notice, "An Important Message from Medicare," (IM, information about the patient's right to appeal their discharge) was provided to one of 32 sampled Medicare patients who were admitted at the time of the survey (Patient 13); and

b. The final IM notice was provided to five of six sampled Medicare patients who had been discharged (Patients 14, 15, 16, 17, and 19).

These failed practices resulted in patients and/or their representatives not having the necessary information to exercise their rights prior to receiving care and discontinuing care.

Findings:

1. A tour of the facility's clinics was conducted with the Director of Outpatient Services on June 15, 2017, at 9 a.m. An interview was conducted with Secretary 1 at the cancer clinic, who stated patients were not provided with a list of their rights prior to beginning their treatment unless they requested a copy.

A tour of the cardiac clinic was conducted on June 15, 2017, at 10 a.m. An interview was conducted with Secretary 2, who stated the patients were not provided with a list of their rights prior to beginning their treatment unless they requested a copy.

A tour of the orthopedic/spine clinic was conducted on June 15, 2017, at 10:45 a.m. An interview was conducted with Receptionist 1, who stated the patients were not provided with a list of their rights prior to beginning their treatment unless they requested a copy.

A tour of the joint clinic was conducted on June 15, 2017, at 11 a.m. An interview was conducted with Receptionist 2, who stated the patients were not provided with a list of their rights prior to beginning their treatment unless they requested a copy.

A review of the facility policy, "Patient Rights and Responsibilities (Revised: 08/2016)" was conducted. The purpose indicated, "To assure that a patient or patient's legal representative is informed of his or her rights and responsibilities upon receiving care and service from (the facility)...Patients are given information about their rights and responsibilities while receiving care, treatment, and services upon admission."

The procedure indicated, "Patients are to be informed of their rights and responsibilities upon admission to an inpatient setting. This will be accomplished by providing the patient with a written statement of the rights and responsibilities as part of the Admitting packet for inpatient admissions, and outpatient surgical patients..." The outpatient clinics were not included in the list of patients that were to be provided with a written statement of their rights.

2. a. On June 14, 2017, at 10 a.m., during a tour of the sixth floor Medical Surgical unit, conducted with the Director of the Sixth Floor Medical-Surgical Unit (D6), Patient 13 was observed lying on her bed.

On June 14, 2017, Patient 13's record was reviewed. Patient 13 was admitted to the facility on on [DATE]. The IM notice was dated May 22, 2017, and indicated, "Pt (patient) unable to sign," on the line for the patient's signature. There were three copies of the IM notice in the patient's record, indicating the patient did not receive a copy.

On June 14, 2017, at 10:08 a.m., D6 was interviewed and stated the Admitting Department was responsible for ensuring the IM notice was signed, dated, and a copy was provided to the patient.

On June 14, 2017 (22 days after Patient 13 was admitted ), at 10:15 a.m., the Admitting Department Supervisor (ADS) was interviewed. The ADS verified all three copies of the IM notice were still in Patient 13's record, indicating the patient did not receive a copy. The ADS stated Patient 13 did not receive her copy of the IM notice. The ADS stated the Admitting Department should have followed up with Patient 13 and/or Patient 13's representative to have the IM notice signed and provide them with a copy within two days of the date of admission.

b.i. On June 15, 2017, the record of Patient 14 was reviewed with the Clinical Information Nursing Analyst (CINA) 1. Patient 14 was admitted to the facility on on [DATE]. The IM notice was dated April 23, 2017, and indicated, "Pt (patient) unable to sign," on the line for the patient's signature. There were three copies in the patient's record, indicating the patient did not receive a copy. Patient 14 was discharged on [DATE].

On June 15, 2017, at 10:38 a.m., the ADS was interviewed and verified all three copies of the IM notice were in Patient 14's record, indicating the patient did not receive a copy. The ADS stated Patient 14 did not receive her copy of the IM notice.

On June 15, 2017, at 1:07 p.m., the ADS was interviewed and stated follow-up with the patients to ensure they received the IM notices prior to discharge was the responsibility of the case management staff.

On June 15, 2017, at 1:19 p.m., Patient 14's record was reviewed with the Director of Case Management (DCM). In a concurrent interview, the DCM stated when the patient's discharge was coming close, the Case Management Department staff should talk to the patient and/or the patient's representative and obtain their signature on the IM notice. The DCM stated the Case Management staff should complete the box on the IM which indicated, "For Case Management Use Only," after reviewing the IM notice with the patient or the patient's representative. The DCM stated Patient 14 did not receive the final copy of the IM notice prior to discharge.

ii. On June 15, 2017, the record of Patient 15 was reviewed with CINA 1. Patient 15 was admitted to the facility on on [DATE]. The IM notice was dated April 23, 2017, and indicated, "Pt (patient) unable to sign," on the line for the patient's signature. There were three copies of the IM notice in the patient's record, indicating the patient did not receive a copy. Patient 15 was discharged on [DATE].

On June 15, 2017, at 10:38 a.m., the ADS was interviewed and verified all three copies of the IM notice were in Patient 15's record, indicating the patient did not receive a copy. The ADS stated Patient 15 did not receive his initial or final copy of the IM notice.

On June 15, 2017, at 2:35 p.m., Patient 15's record was reviewed with the DCM. In a concurrent interview, the DCM stated Case Management did not give Patient 15 the final copy of the IM notice prior to discharge.

iii. On June 15, 2017,at 9:50 a.m., the record of Patient 16 was reviewed with the CINA 2. Patient 16 was admitted to the facility on on [DATE] and discharged on [DATE].

In a concurrent interview, CINA 2 verified there was no documented evidence of the IM notice in the paper or electronic records of Patient 16.

On June 15, 2017, at 2:35 p.m., Patient 16's record was reviewed with the DCM. The DCM confirmed there was no IM notice in Patient 16's records. The DCM stated Patient 16 did not receive the IM notice prior to discharge.

iv. On June 15, 2017, at 9:50 a.m., the record of Patient 18 was reviewed with the CINA 2. Patient 18 was admitted to the facility on on [DATE] and discharged on [DATE].

In a concurrent interview, CINA 2 verified there was no documented evidence of the IM notice in the paper or electronic records of Patient 18.

On June 15, 2017, at 2:35 p.m., Patient 18's record was reviewed with the DCM. The DCM confirmed there was no IM notice in Patient 18's records. The DCM stated Patient 18 did not receive the IM notice prior to discharge.

v. On June 15, 2017, at 9:50 a.m., the record of Patient 19 was reviewed with CINA 2. Patient 19 was admitted to the facility on on [DATE]. The initial IM notice was dated and signed on April 29, 2017. Patient 19 was discharged on [DATE].

On June 15, 2017, at 2:35 p.m., Patient 19's record was reviewed with the DCM. In a concurrent interview, the DCM confirmed there was no documented evidence Patient 19 was provided the final IM notice prior to discharge.

The facility policy and procedure titled, "Notification of Hospital Discharge Appeal Rights (CMS-4105-F)," revised June 2013, was reviewed. The policy indicated, "...Upon admission to the Medical Center, the following steps will be taken to ensure compliance to the regulatory requirement...At the time of admissions process...Inform patient as part of patient rights...The signed IM is required by Medicare...The IM contains information regarding a Medicare patient's appeal rights in the event a patient disagrees with their discharge...A hospital staff member will meet with the patient once a discharge date has been determined to further review the IM...Have patient sign original IM notice...Give patient the copy labeled "Patient (Initial Notice)"...Case Management...Obtain IM form from the chart...Obtain patient signature on form in section labeled "For case management use only" and give copy labeled "Updated Follow-up Notice"...Place original form labeled "Medical Record" on patient chart...After Hours and Sundays...Nursing Supervisor will follow same process ...for Case Management."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0196
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, interview, and record review, the facility failed to ensure:

1. Nine of 15 Public Safety (security) Officers (PSOs 2, 3, 5, 7, 8, 10, 11, 13, and 15) were trained and demonstrated competency in the safe application of behavioral restraints prior to allowing them to perform the function on patients in the Emergency Department (ED); and,

2. 15 of 15 Public Safety Officers (PSOs 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15) were re-trained and demonstrated competency in the safe application of behavioral restraints on an annual basis in accordance with the facility policy.

This failed practice resulted in the potential for unsafe application of restraints in the ED, and the potential for patient harm or death.

Findings:

During a tour of the ED on June 13, 2017, at 12 noon, PSO 1 was interviewed. PSO 1 stated when a patient needed to be put in restraints, the PSO would get, "clearance," from the nurse or the doctor, then apply the restraints or assist the medical personnel in applying the restraints. PSO 1 stated they, "usually," applied four point, "hard," restraints due to the, "nature of the patient," and sometimes they applied a fifth (soft) restraint across the chest. PSO 1 stated the hard restraints had locks on them, and the PSOs and the ED charge nurses had the keys to unlock them. PSO 1 stated he had not received any, "formal," training in the application of restraints.

A clear plastic bag containing hard restraints was observed next to PSO 1. The restraints were burgundy in color, made of hard plastic, and had buttons to push at each point of restraint (both ankles and both wrists) to lock them into place.

During a concurrent interview with the PSO Director (PSOD) and PSO 2 on June 15, 2017, at 10 a.m., PSO 2 stated their job description indicated they would assist with restraint application only, but they had been applying them in the ED. PSO 2 stated she applied restraints on an ED patient the previous night. The PSOD stated the education department was, "working on," developing competencies, but they did not have them yet.

The training file for PSO 2 was reviewed, and indicated she had not been trained or demonstrated competency in restraint application since she started working at the facility (2011).

Using the security log for restraint application, three random restraint records were selected for review on June 15, 2017. The review indicated the following:

a. Patient 43, a [AGE] year old male, presented on June 13, 2017, with altered mental status and alcohol withdrawal. The medical record indicated two point (both wrists) hard restraints were ordered and applied at 8:42 p.m. The security record indicated PSO 3 applied the restraints.

The training file for PSO 3 was reviewed, and indicated he had not been trained or demonstrated competency in restraint application since he started working at the facility (June 13, 2016).

b. Patient 47, a [AGE] year old male, presented on February 9, 2017, with acute alcohol intoxication. The medical record indicated four point (both wrists and both ankles) hard restraints were ordered and applied at 6 p.m. The security record indicated the restraints were applied by PSOs 4 and 5.

The training file for PSO 5 was reviewed, and indicated he had not been trained or demonstrated competency in restraint application since he started working at the facility (August 8, 2016).

c. Patient 48, a [AGE] year old male, presented on June 12, 2017, with an altered level of consciousness and possible overdose of unknown substance. The medical record indicated four point (both wrists and both ankles) hard restraints were ordered and applied at 1:45 a.m. The security record indicated the restraints were applied by PSOs 6, 7, and 8.

The training file for PSO 7 was reviewed, and indicated he had not been trained or demonstrated competency in restraint application since he started working at the facility (November 12, 2015).

The training file for PSO 8 was reviewed, and indicated he had not been trained or demonstrated competency in restraint application since he started working at the facility (February 8, 2016).

Review of the remainder of the PSO employee training files indicated nine of 15 PSOs had not been trained or demonstrated competency in restraint application since they started working at the facility.

During an interview with the Chief Nursing Officer (CNO) on June 16, 2017, at 10:15 a.m., the CNO stated she was unable to find evidence that the nine PSOs (PSOs 2, 3, 5, 7, 8, 10, 11, 13, and 15) had training and demonstrated competence in safe application of restraints prior to allowing them to perform the function on patients in the ED.

2. Using the security log for restraint application, three random restraint records were selected for review on June 15, 2017. The review indicated the following:

Patient 48, a [AGE] year old male, presented on June 12, 2017, with an altered level of consciousness and possible overdose of unknown substance. The medical record indicated four point (both wrists and both ankles) hard restraints were ordered and applied at 1:45 a.m. The security record indicated the restraints were applied by PSOs 6, 7, and 8.

The training file for PSO 6 was reviewed, and indicated he received initial training and demonstrated competency in restraint application on December 3, 2014. There was no evidence of re-training or competency demonstration since that date (two and one half years).

Review of the remainder of the PSO training files indicated no PSOs had received training or demonstrated competency since the last training session was completed for them, on December 3, 2014, two and one half years earlier, when six of the 15 PSOs attended (PSOs 1, 4, 6, 9, 12, and 14). There was no evidence of re-training on a regular basis.

During an interview with the PSO Director (PSOD) on June 15, 2017, at 11:50 a.m., the PSOD stated there was currently no restraint training, re-training, or competency demonstration being done for the PSOs.

The facility policy titled, "Restraint and Seclusion," was reviewed on June 15, 2017. The policy indicated the following:

a. The purpose of the policy was to protect the patient's health and safety, while preserving their dignity, rights, and well-being; and,

b. During the initial orientation period and annually thereafter, all staff working in...Public Safety will be trained in the proper application and use of behavioral restraints.
VIOLATION: QAPI Tag No: A0263
Based on interview and record review, the facility failed to:

1. Develop and implement a Quality Assessment Performance Improvement (QAPI) program that was hospital wide, data driven, involved all departments, and reflected all of the services provided by the hospital;

2. Ensure data was collected and analyzed, and quality indicators were tracked, to ensure improvement in care and services offered at the hospital. (Refer to A273); and,

3. Ensure performance improvement projects were being conducted to reflect the scope and complexity of the services being offered at the hospital. (Refer to A297).

The cumulative effect of these systemic problems resulted in failure to ensure care and services were being offered in a safe and effective manner throughout the organization.

Findings:

The Facility Performance Improvement (PI) Plan, PI meeting minutes, and PI data were reviewed on June 15, 2017. The plan indicated the following:

1. The Quality Care Committee would:

a. Provide a mechanism for associates...to suggest performance improvement activities and receive feedback regarding suggestions submitted and/or implemented;

b. Provide Performance Improvement teams with guidance and support to achieve goals;

c. Review and approve team activities and action plans; and,

d. Review, monitor, and support departmental...performance improvement activities;

2. Hospital department performance improvement included interdepartmental and intradepartmental performance improvement activities as mandated by the standards of practice in the community in the specific discipline and by regulatory agencies; and,

3. Nursing, clinical departments, and support service process improvement activities would be reported at least quarterly to department staff, designated Medical Staff committees, the Quality Care Committee, the Medical Executive Committee, and, "other appropriate hospital committees as necessary."

The Quality Care Committee Meeting minutes (the only minutes provided by the facility regarding QAPI) included reports from infection control, pharmacy, and medical staff departments. There was no evidence of other clinical and non-clinical department managers or staff collecting, analyzing, or reporting data. There was no evidence of ongoing performance improvement projects being conducted in the facility.

On June 15, 2017, at 1:30 p.m., the survey team met with and interviewed the facility leadership team, including:

a. The Chief Nursing Officer (CNO);
b. The Chief Executive Officer (CEO);
c. The Quality Director (QD);
d. The Chief Medical Officer (CMO); and,
e. The Quality Nurse (QN 1).

During the interview, the QD stated a quality dashboard was started and first reported to the Quality Care Committee in March 2017 (3 months earlier). The QD stated there was no department level quality committee or structure, so the data that was collected was not seen by clinical and non-clinical department managers or staff, it was only seen by the members of the Quality Care Committee (a medical staff committee). The QD stated the program was, "not as robust as it should be," and not all departments were sending data to the quality department. The QD stated there were currently no PI projects being conducted based on staff recommendations or suggestions, and there were no PI teams reporting to the Quality Care Committee. He stated the current QAPI program was not hospital wide and did not cover all services offered at the facility.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on interview and record review, the facility failed to ensure data was collected and analyzed, and quality indicators were tracked, to ensure improvement in care and services offered at the hospital. This failed practice resulted in the potential for missed opportunities to improve the quality and safety of patient care throughout the organization.

Findings:

On June 16, 2017, at 8:45 a.m., the survey team met with and interviewed the nursing department managers, including:

a. The Director of Telemetry and Education;
b. The Director of the Emergency Department (ED) and the Cardiac Catheterization Laboratory;
c. The Director of the Medical Surgical Unit/Intensive Care Unit/Oncology/Nephrology; and,
d. The Clinical Educator.

During the interview, the Director of Telemetry and Education stated she was reviewing indicators within her own department, but she did not send any information to quality, she just worked on it within her department.

The Director of ED and Cardiac Catheterization stated she was sending information to the quality department for an ED dashboard, that was reviewed at the monthly ED Medical Staff Committee meetings. She stated her information was not seen by any other department managers or staff, and her data collection did not involve any other departments.

On June 16, 2017, at 9:15 a.m., the facility Performance Improvement (PI) Plan, the Quality Care Committee meeting minutes, and the ED, facility, and corporate dashboards were reviewed with the Director of Quality (DQ). The review indicated the following:

1. According to the PI Plan, data analysis would be done to identify opportunities to improve performance. Analysis would be done on data and information gathered from sources including:

a. Patient satisfaction surveys;

b. Patient safety indicators;

c. Risk management indicators;

d. Review of care or services provided to high risk populations;

e. Restraint use;

f. Resuscitation and Rapid Response Team outcomes;

g. Pain management appropriateness and effectiveness; and,

h. Organizational or departmental measures to evaluate and improve performance.

2. The ED Dashboard data, January thru May 2017, indicated:

a. Falls - the number of falls was documented, with, "no goal indicated." There was no analysis of the data to determine whether there were opportunities for improvement;

b. Code Blue - the number of codes was tracked, with no survival or mortality information to assess the quality of services provided by the code blue team, and, "no goals indicated;"

c. Medication reconciliation - the goal was 100% compliance, but the actual compliance was 76-81%. There was no analysis of the data and no plan for improving performance;

d. Behavioral restraints - The goal was 100% compliance, but the actual compliance was 14-47%. There were no specific indicators to assist in analyzing the type of non-compliance, improve performance, or improve patient safety;

e. Procedural sedation - The goal was 100% compliance, but the actual compliance was 0-25%. There were no specific indicators to assist in analyzing the type of non-compliance, improve performance, or improve patient safety; and,

f. Re-evaluation of pain after intervention - The goal was 90% compliance, but the actual compliance was 10-67%. There were no specific indicators to assist in analyzing the type of non-compliance, improve performance, or improve patient outcomes.

Review of the dashboard revealed data was being collected, but no analysis was being conducted to identify actions necessary to improve quality.

3. The Facility Dashboard, January thru April 2017, indicated:

a. Falls - the number of falls was documented, with, "no goal indicated." There was no analysis of the data to determine whether there were opportunities for improvement;

b. Pressure Ulcers - no goal was indicated, and no data was available. During a concurrent interview, the DQ stated the data (total numbers of pressure ulcers only) came from the risk management system, but they did not currently have a risk manager, so no data was available;

c. Code blue - no goal was indicated and no data was available. During a concurrent interview, the DQ stated there was not a current code blue committee, so no data was being tracked or analyzed to assess the quality of the services provided by the code blue team;

d. Restraints - no goal was indicated, and no data was available. During a concurrent interview, the DQ stated there was no restraint data being reported to the quality department (except for the data reported by the ED that was reviewed by the ED Medical Staff Committee);

e. Sepsis (super infection) bundle appropriate care - the goal was 100% compliance, but the actual compliance was 90%, down to 69%, down to 50%. There were no specific indicators to assist in analyzing the type of non-compliance, determine the reason for the decrease in compliance, improve performance, or improve patient outcomes; and,

f. Patient satisfaction surveys - the facility was below their target goals for nine of 11 indicators in January, and 10 of 11 indicators in February, March, and April. There was no analysis of the data to determine areas to target for improvement.

Review of the dashboard revealed data was being collected inconsistently, and no analysis was being conducted to identify actions necessary to improve quality.

4. The Corporate dashboard, April 2016 thru April 2017, indicated:

a. Catheter associated urinary tract infections - the facility was over their targeted goals (too many infections) for five of the past 12 months. There was no analysis of the data to determine areas to target for improvement;

b. Sepsis perfect care rate - the facility was under their targeted goal (not appropriately caring for the septic patient) for eight of the past 12 months. There was no analysis of the data to determine areas to target for improvement.

Review of the dashboard revealed data was being collected, but no analysis was being conducted to identify actions necessary to improve quality.

During a concurrent interview with the DQ, the DQ stated he started at the facility in March 2017 (three months earlier), and the quality department up to that time had been there solely to support medical staff functions. The DQ stated he realized the need for interdepartmental and intradepartmental performance improvement projects and indicators that involved all hospital departments and covered all services offered at the facility. He stated he started gathering data and reporting on quality dashboards in March 2017, but the data had not been analyzed and no indicators had been put into place to work on improving performance.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observation, interview, and record review, the facility failed to ensure hospital beds were inspected and maintained according to manufacturer's recommendations.

This failure resulted in the potential for an inaccurate patient assessment (bed scale), patient discomfort (bed controls), and patient harm or death (brakes, siderails, CPR release handles).

Findings:

On June 15, 2017, at 8 a.m., the Director for Facilities Management (DFM) was interviewed. The DFM stated hospital beds that had preventive maintenance done in 2017 would have red dot stickers by the foot of the bed.

During a tour of the Intensive Care Unit (ICU) on June 13, 2017, at 3:05 p.m., five of five patient beds were observed without a sticker to indicate when preventive maintenance had been performed. (Rooms 423, 424, 425, 426, and 427).

On June 15, 2017, at 3 p.m., a tour of the Intensive Care Unit and fifth floor Telemetry unit was conducted with the DFM. 19 ICU and 12 Telemetry beds were observed without red dot stickers.

On June 16, 2017, at 8:26 a.m., the DFM was interviewed. The DFM stated there was, "no way," to track how many beds had preventive maintenance or how many beds needed to have preventive maintenance done for 2017. The DFM stated the beds that were broken and repaired were the only ones that had preventive maintenance. The DFM stated preventive maintenance was only being done if a bed was broken and had to be repaired. The DFM stated, "Beds don't get preventive maintenance until they break." The DFM stated "If I had known preventive maintenance was required, I would have done it." The DFM stated, "Less than half of the beds on the floors have had preventive maintenance."

On June 16, 2017, at 8:30 a.m., the Intensive Care Unit Director (ICU-ND) was interviewed. The ICU-ND stated the ICU beds were each equipped with a scale that they used to monitor daily patient weights, siderails and brakes to keep patients safe, bed controls for patient positioning and comfort, and CPR emergency release handles that allowed immediate access during emergencies. The ND stated the maintenance of the ICU beds was important in providing care and keeping patients safe.

On June 16, 2017, at 9:21 a.m., the Telemetry Unit Director (T-ND) was interviewed. The T-ND stated the bed scale, brakes, bed controls, and siderails were important for patient care and safety.

On June 16, 2017, the hospital bed maintenance manuals for the three types of beds used in the facility were provided by the DFM for review. The manuals indicated the following:

a. Stryker GoBed II MedSurg Bed Model FL28C, "Beds require an effective maintenance program. We recommend checking these items annually...ensure that the brakes are applied and bed is immobilized...Siderails move, latch, and stow properly...Calibrate the scale...All siderail controls working properly...Verify the CPR emergency release..."

b. Stryker MedSurg Bed Model 3002 S3,"Beds require an effective maintenance program, we recommend checking these items annually...engage brake pedal...Inspect brake assembly...Siderails move, latch and stow properly...CPR releases working properly...Scale and Bed Exit system work properly..."

c. Century CC Bed, "The Century CC Bed must have an effective maintenance program. We recommend you perform preventive maintenance and testing...semi-annually..."
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, interview, and record review, the facility failed to ensure:

1. Contact isolation precautions were maintained for one sampled patient (Patient 34), resulting in the potential for spread of infection to patients, staff, and visitors;

2. Protective isolation precautions were maintained for one patient (Patient 3), resulting in the exposure of an already immunocompromised patient to potential infections;

3. RN 2 removed her personal protective equipment (PPE- gown and gloves used to prevent the spread of infection) before she stepped into the hallway after coming out of a contact isolation room, resulting in the potential for spread of infection to other patients, staff, and visitors;

4. An isolation room in the Short Stay Unit was disinfected according to manufacturer's recommendations, resulting in the potential for spread of infection to other patients, staff, and visitors;

5a. The soiled linen and contaminated linen was kept secured and out of public reach, resulting in the potential for spread of infection to the community; and,

5b. A cart with 50-4 gallon used sharps (used needles, syringes, scalpels, broken glass, etc.) containers were kept secured and out of public reach, resulting in the potential for spread of infection to the community.

Findings:

According to the Centers for Disease Control and Prevention (CDC), contact isolation precautions are to be used for:

a. Patients known or suspected to be infected or colonized with microorganisms that are transmitted by direct contact with the patient; and,

b. Indirect contact with the environmental surfaces or personal care items of the infected or colonized patient.


1. A tour of the fifth floor nursing unit was conducted on June 13, 2017, at 2:30 p.m. A sign posted on the outside of room 510 indicated the patient (Patient 34) was on contact isolation precautions.

On June 13, 2017, at 2:45 p.m. RN 1 was observed entering Patient 34's room without donning (putting on) gloves or a gown, walking to Patient 34's bedside, and leaning on the side rail to adjust an intravenous infusion of blood the patient was receiving.

An interview was conducted with RN 1 on June 13, 2017, at 2:55 p.m. RN 1 stated he should have put on gloves and a gown prior to providing care to Patient 34.

A review of Patient 34's record was conducted. Patient 34 was admitted to the facility on on [DATE], with a urinary tract infection and a diagnosis of sepsis (a life threatening infection). Patient 34 was found to have Extended Spectrum Beta-Lactamase producing Enterobacteriaceae (ESBL - a bacteria that is resistant to multiple antibiotics) in his urine. Patient 34's physician ordered continuous contact isolation precautions for the patient on June 5, 2017, at 11:55 p.m.

A review of the facility policy, "Isolation (Transmission Based) Precautions Protocol (Revised: 06/2011)," was conducted. The policy indicated contact isolation precautions required gloves to be worn during the course of providing care for a patient...gowns were to be worn when there was a substantial contact with the patient, environmental surfaces, or items in the patient's room.

2. On June 13, 2017, at 10:15 a.m., an initial tour of the seventh floor south medical-surgical unit was conducted with the Chief Operating Officer (COO) and Nursing Director (ND). A sign posted outside the door of room 733 indicated the patient (Patient 3) was in protective isolation, and a face mask was required to be used by anyone entering the room.

On June 13, 2017, at 10:30 a.m., three hospital staff were observed without face masks inside of room 733. The staff were observed having a conversation with Patient 3.

In a concurrent interview with the COO and ND, the COO stated the facility staff should have been wearing face masks. The ND stated the three hospital staff were pharmacists.

On June 13, 2017, Patient 3's record was reviewed. Patient 3 was admitted to the facility with diagnoses that included status post kidney transplant requiring immunosupressant medications (medications that weakened the immune system and the body's ability to fight infection). Patient 3's physician's orders indicated, June 12, 2017, 6 p.m., Neutropenic Isolation Precautions (initiated for immunocompromised patients who are at high risk for numerous types of infections while receiving healthcare).

The facility policy and procedure titled, "Precautions in Immunocompromised Patients," last revised, November 2016, indicated,"PROCEDURE A. Protective Isolation: 1. Private room with door closed 2. Meticulous hand hygiene when caring for the patient 7. Mask is used by all hospital staff and visitors when entering patient room..."

3. A tour of the sixth floor nursing unit was conducted on June 13, 2017, at 11 a.m., with the Director of the Sixth Floor Medical- Surgical Unit (D6) and Clinical Support Analyst (CSA) 1. A sign posted outside the door of room 632 indicated the patient (Patient 9) was on contact isolation precautions.

On June 13, 2017, at 12:15 p.m., RN 2 was observed coming out of room 632 wearing an isolation gown and gloves on both hands. RN 2 was observed removing the isolation gown and placing it in a trash bin in the hallway outside of room 632's doorway. Afterwards, RN 2 was observed removing both gloves from her hands and placing them in the same trash bin.

On June 14, 2017, at 10:30 a.m., the facility policy titled, "Standard Precautions," revised November 2016, was reviewed with D6. The policy indicated, "...Before leaving the patient's room or cubicle, remove and discard PPE..."

In a concurrent interview, D6 stated the facility policy should be followed. D6 stated RN 2 should have removed the PPE prior to coming out of Patient 9's room.

4. During a tour of the Short Stay Unit on June 14, 2017, at 9:40 a.m., Housekeeper 1 was observed cleaning Room 4 after the room was vacated by a patient who had Methicillin Resistant Staphylococcus Aureus (MRSA - a contagious bacteria that is resistant to many antibiotics).

The housekeeper was observed wiping down all surfaces in the room (chairs, cabinet surfaces, bedside table, glove holders, window sills, television, wall outlets, and the vital signs machine) with a microfiber cloth containing Ecolab A-456 II Disinfectant Cleaner. The housekeeper wet the cloth one time, wrung it out, and cleaned the entire room with the same cloth. The solution from the cloth dampened the surfaces as they were wiped. The surfaces remained wet (contact time - the time the disinfectant remains in contact with the surfaces) for less than two minutes.

During an interview with Housekeeper 1 on June 14, 2017, at 9:50 a.m., the housekeeper stated the surface should remain wet for, "five minutes, sometimes ten." The housekeeper was not able to explain when a surface should remain wet for five minutes and when it should remain wet for 10 minutes. She stated, "It depends."

The manufacturer's recommendations for Ecolab A-456 II Disinfectant Cleaner were reviewed on June 14, 2017. The recommendations indicated, "Contact time: Leave surface wet for one minute (60 seconds) for HIV-1 (the virus that, over time, causes acquired immunodeficiency syndrome [AIDS])....Use a 10-minute contact time for disinfection against all other viruses, bacteria, and fungi."

5. On June 15, 2017, at 9:30 a.m., an environmental tour was conducted with the Compliance Officer (CO) and the Environmental Services Director (EVSD). The hospital rear driveway was observed adjacent to the public street with opened gates. The EVSD stated gates were kept open from 4 am through 4 p.m., Monday through Friday.

a. Facing the open gated driveway was a storage room observed unattended, with wide open double doors containing large quantities of bagged, soiled linen (available for anyone to open, agitate, and contaminate air, surfaces, and persons). Both doors had a red sign that read,"WARNING SOILED LINEN DOORS MUST BE CLOSED AT ALL TIMES." The EVSD stated the storage room was where all the soiled hospital linen was kept and stored. The EVSD stated the doors should have been closed since the gates were wide open.

According to the Centers for Disease Control and Prevention (CDC), soiled linen has been identified as a source of large numbers of pathogenic microorganisms and requires hygienic and common-sense storage and processing. Furthermore, contaminated textiles and fabrics should be handled with minimum agitation to avoid contamination of air, surfaces, and persons.

b. A cart with 50 - 4 gallon used sharps containers was observed unattended and unsecured close to the open driveway gate. The cart was sitting beside a locked gate enclosure (cage). The EVSD stated the sharps containers should have been, "inside the locked cage," by the driveway. The EVSD stated the cart of used sharps containers should not have been, "left in the open," and accessible to the public. The CO stated, "It is concerning, anyone could have come and picked up the sharps."

According to the Food and Drug Administration (FDA), used needles and other sharps are dangerous if not disposed of safely because they can injure people and spread infections that cause serious health conditions. The most common infections include Hepatitis B and C, and Human Immunodeficiency Virus (HIV).