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.

ST MARY CORWIN MED CTR, CENTURA HEALTH 1008 MINNEQUA AVE PUEBLO, CO 81004 March 21, 2018
VIOLATION: SURGICAL SERVICES Tag No: A0940
Based on the nature of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation 482.51, SURGICAL SERVICES, was out of compliance.

A-0951 - Standard: Delivery of Service - Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. The facility failed to ensure surgical services were provided in accordance with established standards of care, specifically related to continued use of Immediate Use Steam Sterilization (IUSS) and had not implemented efforts to decrease the routine use of IUSS. Four of eight medical records reviewed for surgical services had IUSS performed (Patient #4, #6, #7 and #11).
VIOLATION: OPERATING ROOM POLICIES Tag No: A0951
Based on observations, document review and interviews the facility failed to ensure surgical services were provided in accordance with established standards of care, specifically related to continued use of Immediate Use Steam Sterilization (IUSS) and had not implemented efforts to decrease the routine use of IUSS. Four of eight medical records reviewed for surgical services had IUSS performed (Patient #4, #6, #7 and #11).

Finding include:

Policies:

According to the policy, Sterile Processing Procedures, sterilization provides the highest level of assurance that surgical items are free of viable microbes. Immediate Use Steam Sterilization (IUSS) will be minimized.

References:

According to The Association of Perioperative Registered Nurses (AORN) guidelines for 2016, IUSS should be kept to a minimum and should be used only in select clinical situations and in a controlled manner. IUSS may be associated with increased risk of infection to patients. Time constraints may result in pressure on personnel to eliminate of modify one or more steps in the cleaning and sterilization process. IUSS use in considered the shortest time possible between a sterilized item's removal from the sterilizer and it's aseptic transfer to the sterile field.

According to the Centers for Medicare and Medicaid Services S&C Memo 14-44 Hospital/CAH/ASC, consistent with standards of practice previously articulated by national associations with expertise in infection prevention, the availability of IUSS is not considered an appropriate substitute for maintaining a sufficient inventory of instruments.

1. The facility failed to ensure items needed for surgeries were sterilized and available for use to prevent the use of IUSS as an alternative.

a. A tour of the perioperative area was conducted on 3/19/18 at 12:10 p.m. sterile processing technician (SPT) #7 was observed working in the sterile corridor. Steam sterilizer #2 was observed currently in use. SPT #7 stated the facility currently had three steam sterilizers used for IUSS. SPT #7 identified the facility was using IUSS and stated the reasons were: vendors brought in a tray and only had one tray for multiple cases and limited inventory issues.

A follow-up interview was conducted with SPT #7 on 3/20/18 at 9:30 a.m. who stated she had notified leadership, to include the Perioperative Manager #1, of the increased use of IUSS two weeks ago. SPT #7 stated a list was created, the list included instruments which were sterilized utilizing IUSS routinely. Additionally the list included instruments in which the facility only had one in inventory.

b. The Infection Control Clinical Effectiveness committee meeting minutes from September 2017 were reviewed and revealed discussion with IUSS comparisons and a benchmark of 3% was identified. According to the meeting minutes perioperative staff were to track and monitor for trends. An interview with the regulatory manager (Manager #8), on 03/21/2018 at 2:03 p.m. stated the goal had been 3% since she had been in her position over 10 years.

The 2016 IUSS rates for the facility were documented as 12.5%. Four times higher than the facility identified benchmark of 3% with the highest month (September) being 17.79%. The 2017 data from January to July was reviewed with 13.36% as the total percentage of IUSS. The highest month was 17.87% for June, 2017.

c. Review of IUSS data provided by Manager #1 revealed in December, 2017 IUSS was performed a total of 52 times. January, 2018 IUSS was performed at total of 31 times. February, 2018, IUSS was performed a total of 45 times. An updated IUSS percentage rate was provided which indicated December, 2017 IUSS rate was 13.51%, January, 2018 rate was 9.78% and February, 2018 was 13.95%.

d. Review of the three IUSS logs for the month of March revealed on 3/13/18, Patient #11 was documented to have three separate entries in the log. Listed for Patient #11 was reduction forceps, a Kinamed set, stilettos and cables. During an interview on 3/21/18 at 2:49 p.m., Manager #1 stated infection was a risk with using IUSS. On review of the IUSS log for Patient #11, Manager #1 stated IUSS was used, instead of the standard sterilization process, due to lack of inventory. Additionally, Manager #1 stated IUSS on multiple instruments for one surgery put a patient at increased risk for infection.

e. On 3/20/18 at 10:50 a.m. a surgical case tracer for Patient #7 was conducted. During the case tracer SPT #7 was observed bringing in a trimano adapter (a connector to an arm support). On review of the IUSS log, the trimano adapter was logged as IUSS for Patient #7. During an interview on 3/21/18 at 2:49 p.m. Manager #1 stated SPT #7 was unable to locate the other two trimano adapters the facility had and confirmed IUSS was used for the trimano adapter for Patient #7's surgical case.

Similar finding were found for Patient #4 and #7, with each patient having an entry on the IUSS log for their surgical procedure. On review of the entry for Patient #6, the reason documented for IUSS was equipment turnover. On review of the entry in the log for Patient #7, the reason documented for IUSS was the vendor brought in the equipment.

f. On 03/21/2018 at 2:03 p.m. an interview was conducted with the regulatory manager (Manager #8). Manager #8 stated the facility had multiple leadership changes and could not provide any evidence the facility had taken steps to minimize the routine use of IUSS since 2016.
VIOLATION: TIMELY DISCHARGE PLANNING EVALUATIONS Tag No: A0810
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interviews the facility failed to ensure the patient's post discharge services were arranged in a timely manner prior to leaving the facility. The facility also failed to ensure the patient received adequate discharge education prior to leaving the facility. These failures were identified in 1 of 4 medical records (Patient #3) reviewed for patients that required home health services post-discharge.

The failure led to Patient #3 being discharged from the facility without home health services arranged prior to leaving the facility.

Findings include:

Facility policy:

The policy, Case Management and Discharge Planning, stated the purpose of the discharge planning "process is to ensure all of the patient's post-discharge needs are care coordinated throughout the care continuum." Case management facilitates discharge planning for patients, in collaboration with the multidisciplinary care team, and makes appropriate arrangement for post hospital care.

The policy, Case Management and Discharge Planning, also stated the hospital would consult with the patient, legal representative, and caregiver of the discharge plan and aftercare needs prior to release from the hospital. Furthermore, the hospital is required to ensure the patient's services were monitored for appropriateness, timeliness, availability, and cost efficiency. Lastly, the discharge plan must include the contact information for any health care, community resource, long-term services, and support necessary to carry out the patient's discharge plan.

1. The facility failed to ensure the patient's post discharge services were arranged in a timely manner prior to leaving the facility. The facility also failed to ensure the patient received adequate discharge instructions prior to leaving the facility.

a. Medical record review for Patient #3 found the [AGE] year old patient underwent an elective surgical laminectomy (a surgical operation to remove the back of one or more spinal vertebrae, usually to give access to the spinal cord or to relieve pressure on nerves) on 9/13/17. The patient was admitted to the intensive care unit post-operatively, and subsequently transferred to an orthopedic unit once medically cleared. Further review of the medical record found the patient required home health services as part of the discharge plan. The discharge plan included home health care with physical therapy, occupational therapy, and registered nurse services. At the time of discharge the patient had a surgical wound site present, a urinary catheter (a flexible tube which a clinician passes through the urethra and into the bladder to drain urine) in place because of urinary retention, and post-surgical physical mobility deficits.

Patient #3 was discharged from the facility on 9/18/17 at 9:56 a.m. without any of the identified post-discharge services arranged and in place prior to leaving the facility. According to the case manager's (CM #3) documentation note on 9/18/17 at 12:40 p.m., the patient's insurance provider had not preauthorized the patient's surgery or hospital visit and was unable to arrange the post-discharge services. CM #3 documented the patient was already discharged from the facility upon discovering the lack of coverage available from the insurance provider. According to the documentation at that time, CM #3 called the listed phone number for the discharged "patient and his wife and left messages recommending they immediately call their primary care provider and explain the situation and their immediate needs."

Patient #3 had already been discharged from the facility prior to case management confirming an accepting home health agency to provide physical therapy, occupation therapy, and nursing services.

b. Review of Patient #3 discharge instructions, located in the After Visit Summary (AVS) of the medical record, also found no evidence the patient received catheter education prior to discharge. There was also no evidence in the AVS the patient and designated caregiver were instructed regarding how the catheter would be managed at home with the home health clinician.

c. On 3/21/18 at 9:23 a.m., an interview was conducted with CM #3 who was responsible for the post-discharge arrangements for Patient #3. CM #3 stated prior to discharge the patient should have received the name and contact agency for the home health agency which accepted the patient to provide post-discharge services.

After reviewing the medical record for Patient #3, CM #3 confirmed the patient was discharged from the facility prior to confirmation the home health agency had accepted the patient. CM #3 also confirmed the AVS documentation, provided to Patient # 3 and their designated caregiver prior to leaving the facility, had not contained the contact information for a home health agency.

CM #3 stated there was a problem with the patient's insurance provider identified on the day of discharge. Therefore, the orders for home health services were entered by the physician but unable to be arranged due to insurance issues at that time. CM #3 stated Patient #3 was discharged "faster than expected that day" and was unable to resolve the discharge plan prior to the patient leaving the facility.

d. CM #3 stated his leadership had provided education once gaps in Patient #3 discharge plan were identified from a case review. He stated the facility education focused on avoiding delays from certain insurance providers. CM #3 stated the current discharge process recommended arranging home health prior to discharge but was not required before the patient left the facility. CM #3 stated home health referrals could still be completed after a patient was discharged from the facility.

e. On 3/21/18 at 9:40 a.m., an interview with a case manager (CM #4) confirmed patients were not required to have an accepting home health agency prior to discharge from the facility. It was also stated referrals could be sent after the patient left the facility. CM #4 stated in those instances patients could possibly wait 2-3 days before being seen depending on the availabilities of the accepting agency.

f. On 3/21/18 at 11:26 a.m., an interview was conducted with the manager of case management (Manager #5). According to Manager #5, establishing and arranging the discharge plan was important in order to provide continuity of care to patients leaving the facility.

Manager #5 stated once a patient's referral for a home health services were accepted, the name and contact information should be documented in the medical record. Also, the name and contact information for the home health agency should be documented in the patient's After Visit Summary (AVS) provided just before discharge from the facility.

Manager #5 stated patients should not be discharged before an accepting home health agency was arranged, but it did happen on high turnover patient care units. It was also stated patients could be discharged on the weekend, and the home health agency may not have accepted patients on the weekends. Manager #5 stated in those instances a patient could be discharged from the facility, and the referrals could be submitted later at the start of the next business day. Lastly, if an issue were to arise arranging home health after the patient was discharged then the patient could be instructed to contact their primary care provider.

g. Manager #5 stated the facility received a complaint regarding Patient #3's discharge plan and quality of care. According to the interview, a Root Cause Analysis (RCA) review of the case was completed by the facility's leadership. Manager #5 confirmed gaps in the discharge plan were identified from the RCA review. In regard to case management and social workers, Manager #5 stated she educated the staff on improving communication with certain insurance providers in order to prevent delays. She also stated there were increased discharge rounding meetings arranged in order to update the interdisciplinary team members of the patient's status. However, Manager #5 stated it was still currently possible patients may be discharged before an accepting home health agency was arranged and confirmed.

Manager #5 confirmed that patients discharged before an accepting home health agency was in place could possibly delay post-discharge services after leaving the facility and cause potentially negative outcomes for the patient.

h. On 3/21/18 at 11:00 a.m., an interview was conducted with a registered nurse (RN #6). According to the interview, the discharging nurse should ensure all areas of the discharge plan were confirmed and put in place before the patient left the facility. RN #6 also stated if a patient required home health services then the contact information for the accepting agency should be included in the discharge instructions provided to the patient. She stated it was necessary to ensure post-discharge services were available so patients had everything they need for discharge in place before they left the facility.

RN #6 also confirmed that patients discharged with a new urinary catheter in place should have been provided verbal and written instructions on how the catheter would be managed once discharged .

That was in contrast to the discharge plan provided to Patient #3, where no home health agency had been arranged prior to the nurse discharging the patient. There was also no evidence the patient was provided verbal or written instructions on how the catheter would have been managed post-discharge.