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.
|PRISMA HEALTH HILLCREST HOSPITAL||741 SOUTH EAST MAIN STREET SIMPSONVILLE, SC 29681||Sept. 3, 2015|
|VIOLATION: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT||Tag No: A0308|
|Based on review of the hospital's contractural arrangements and interview, the hospital failed to ensure that monitoring and assessing its contractural services(physical therapy) provided through arrangement are included in its hospital wide Quality Assessment Performance and Improvement (QAPI) program.
The findings are:
Cross Reference to A 0083: The hospital failed to provide evidence of monitoring of the physical therapy services through its hospital wide Quality Assessment Performance Improvement (QAPI) program.
|VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES||Tag No: A0749|
|Based on observations and interview, the hospital failed to ensure 2 of 2 environmental services (EVS) staff performed hand hygiene after glove removal (EVS 1 and 2), 1 of 1 Certified Registered Nurse Anesthetist (CRNA) 1 performed hand hygiene after glove removal, failed to ensure the operating room staff performed terminal cleaning after surgical cases on the weekends, and Patient Care Technician( PCT) 2 cleaned the glucometer after use on a patient, PCT 1 failed to follow manufacturer's instructions when cleaning the operating room table, and EVS 2 removed and/or cleaned the CPM left on the bed after the patient was discharged .
The findings are:
On 09/02/15 at 1:30 p.m., observations of cleaning if a patient's room after the patient's discharge revealed a continuous pressure machine (CPM) attached to the end of the bed that was not cleaned during the cleaning of the empty patient room. On 09/02/15 at 2:05 p.m., EVS 2 revealed that after cleaning the empty patient room that the CPM was not cleaned because I thought it was already done.
On 09/02/15 at 1:34 p.m., observations of the hospital's environmental service (EVS) staff cleaning an empty patient room revealed EVS Staff 1 removed the soiled gloves after cleaning a recliner, but failed to to perform hand hygiene prior to donning a clean pair of gloves. On 09/02/15 at 2:00 p.m., EVS 1 revealed, "I didn't recline the chair during disinfection. I try to perform hand hygiene every time I take my gloves off".
On 09/02/15 at 1:47 p.m., observations of EVS Staff 2 cleaning an empty patient room revealed EVS Staff 2 removed the soiled gloves but failed to perform hand hygiene prior to donning a clean pair of gloves.
On 09/03/15 at 11:10 a.m., random observations in Operating Room 2 revealed CRNA 1 intubated a patient, removed the soiled gloves, donned a clean pair of gloves, but failed to perform hand hygiene prior to donning the clean gloves.
On 09/03/15 at 11:30 a.m., random observations in Operating Room 1 revealed Patient Care Technician (PCT) 1 cleaned the operating room table post and then, fanned the operating room table to dry the table. On 09/03/15 at 11:45 a.m., PCT 1 revealed that the disinfectant which used for the operating room tables is allowed to completely dry. Review of manufacturer's guidelines revealed, "Apply to hard non-porous surfaces. Allow to remain wet for 5 minutes. For non-food contact sanitizing, allow to remain wet for 3 minutes. Wipe and let air dry....".
On 09/03/15 at 1:30 p.m., review of the hospital's operating room schedule for July 2015 revealed scheduled operating room (OR) cases on the following weekend days: 07/11/15 OR 1, 07/12/15 OR 1, 07/25/15 OR 1 and 07/26/15 OR 1. Review of August 2015 operating room schedule revealed weekend OR cases scheduled on the following weekend days: 08/01/15 OR 1, 08/08/15 OR 1, 08/09/15 OR 4, 08/16/15 OR 1, 08/22/15 OR 1, and 08/29/15 OR 1. Review of the terminal cleaning log for the OR for July 2015 and August 2015 revealed there was no documentation of terminal cleaning for those days.
On 09/03/15 at 4:20 p.m., observations of blood glucose checks revealed Patient Care Technician (PCT) 2 was observed with the entire glucometer meter and case in a patients room to obtain a glucose check. Observations revealed the glucometer case was placed on the patient's bedside table. After the finger stick blood sugar check, the glucometer case was removed from the patient room, placed on a cart outside of the patient room, and then, returned to the nurse station without disinfection of the outer case. On 09/03/15 at 4:25 p.m., PCT 2 revealed, "I usually take everything in with me so if I don't get it the first time, then, I don't have to keep running back and forth".
Hospital policy, titled, "Cleaning the Surgery Department, Policy:", reads, "The Environmental Services Department personnel (or assigned staff) will clean/disinfect the Surgery Department daily. Each Operating Room (if used) will be terminally cleaned daily with the hospital approved disinfectant....".
Hospital policy, titled, "Non-critical items/Equipment Cleaning and Disinfection Guidelines", reads, "....Table 1. Non-critical patient care equipment, patients in expanded precautions, all equipment that is taken into the room of a patient who is in expanded precautions must be disinfected prior to use on other patients....".
|VIOLATION: CONTRACTED SERVICES||Tag No: A0083|
|Based on review of the hospital's contractual agreements for physical therapy services, and interview, the hospital failed to provide evidence of monitoring of the physical therapy services through its hospital wide Quality Assessment Performance Improvement (QAPI) program.
The findings are:
On 09/04/15 at 3:30 p.m., review of the hospital's contracts and arrangements revealed the hospital's physical therapy services are acquired through arrangement from another facility. Review of the hospital's interdisciplinary performance improvement reporting schedule for 2015 revealed the physical therapy services wasn't covered by the schedule. On 09/04/15 at 3:35 p.m., Registered Nurse 3 revealed, "since physical therapy rarely comes, it is not monitored by the Quality Council".
|VIOLATION: PATIENT SAFETY||Tag No: A0286|
|Based review of the hospital's adverse events and interview, the hospital failed to ensure 1 of 3 adverse events reviewed identified underlying causes, identified all parts of the hospital utilizing similar processes/at similar risk, and developed preventative actions. Also, 3 of 3 adverse events reviewed failed to evaluate preventative actions including tracking reoccurrences.
The findings are:
On 09/04/15 at 2:05 p.m., review of the hospital's adverse events revealed an adverse event dated 01/22/15. Review of the documentation for the adverse event revealed there was no hospital identification of potential underlying causes or contributing factors, no identification of all parts of the hospital utilizing similar processes/at similar risk, no development and implementation of preventative actions, and no preventative actions including tracking reoccurrences of similar events, close calls, and/or near misses. On 09/04/15 at 2:15 p.m., Registered Nurse (RN) 1 revealed the former chief nursing officer covered the report and verified the finding.
On 09/04/15 at 2:30 p.m., review of an adverse event dated 05/21/15 revealed there was no documented preventative actions including tracking reoccurrences of similar events, close calls, and/or near misses. On 09/04/15 at 2:35 p.m., Certified Registered Nurse Anesthetist (CRNA) 2 revealed there was another incident on 05/14/15 which was not documented in the adverse events log. CRNA 2 reported, "everyone was told about the event. We just stopped doing what we were doing until a report came back from the manufacturer. There was no other follow-up or tracking performed".
On 09/04/15 at 2:35 p.m., review of adverse event dated 04/24/15 revealed there was no documented preventative actions including tracking reoccurrences of similar events, close calls, and/or near misses. On 09/04/15 at 2:40 p.m., RN 1 revealed, " the information was just reviewed, but there was no further action was performed".