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.
| GLEN OAKS HOSPITAL | 301 E DIVISION BOX 1885 GREENVILLE, TX 75401 | June 26, 2018 |
| VIOLATION: PATIENT RIGHTS | Tag No: A0115 | |
| Based on observation, review of records, and interview, the facility failed to: A. ensure all written complaints were processed as grievances during 5 (December 2017, January, February, April and May 2018) of the previous 6 months reviewed (December 2017 through May 2018). (See Tag A0118) B. provide for a safe environment for 6 (Patient #1, #6, #7, #, 8, #9, and #13) of 13 patients reviewed. Medical equipment used in the treatment of patients presented potential risks when used in psychiatric settings. No evidence was found that risks were identified or mitigated (safety measures in place to lessen or remove the risk of harm to staff and patients) when potentially hazardous medical equipment or devices were used for patient care. Patient #9 was suicidal and had access to a ligature (something used for tying or binding something tightly) risk. Ligatures can be used by a psychiatric patient to commit suicide or to choke staff or other patients. In this case, the ligature was an oxygen nasal cannula used to deliver oxygen to the patient while sleeping) and ligature attach point (a walker). Patient #13 was recently admitted after an illness, required a walker to be able to walk, and was placed on a unit with a patient (Patient #1) who was aggressive and had assaulted staff three times and destroyed property. Patient #13 got into a verbal altercation with Patient #1 while using a walker for mobility. The verbal altercation threatened to turn physical. The walker could have easily been taken away from the patient and used as weapon to harm Patient #13. Patient #13 could have used the walker as a weapon to defend himself during the verbal altercation with Patient #1. Additionally, Patient #6, 7, and 8 were using walkers for assistance with mobility. Records did not demonstrate an identification of potential risk or consideration of mitigation to that risk. These conditions create an Immediate Jeopardy situation for all patients when a patient enters the hospital with a need for oxygen and/or use of a mobility aid. These deficient practices were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death. (See Tag A0144) |
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| VIOLATION: PATIENT RIGHTS: GRIEVANCES | Tag No: A0118 | |
| Based on review of records and interview, the facility failed to ensure all written complaints were processed as grievances during 5 (December 2017, January, February, April and May 2018) of the previous 6 months reviewed (December 2017 through May 2018). Review of the Complaint Log was as follows: December 2017 - 6 hand-written complaints from patients not processed as grievances. January 2018 - 1 hand-written complaint from patient not processed as grievance. February 2018 - 1 hand-written complaint from patient not processed as grievance. March 2018 - No complaints logged. April 2018 - 4 hand-written complaints from patient or patient family not processed as grievances. May 2018 - 3 hand-written complaints from patient not processed as grievances. Review of the Policy Title: Complaint/Grievance Resolution; Policy Number: ADM.22; Effective Date: 11/2017; was as follows: "II. Grievance Defined A "patient grievance" is a formal or informal written or verbal complaint of a problem or concern which an individual needs assistance resolving, including a complaint of unfair treatment that cannot be resolved promptly by staff present. Not all patient inquiries and requests for explanation are considered grievances. Most can be resolved within the regular relationship between patients and Glen Oaks staff. Efforts are made to resolve issues with the staff present and reach a consensus with the patient on a plan of action to resolve the problem informally unless the patient desires to proceed with the grievance process. At the request of the patient, an unresolved problem, concern, complaint, or dispute is processed as a grievance. A complaint is considered resolved when the patient is satisfied with the actions taken on their behalf. "Staff present" includes any hospital staff present at the time of the complaint or who can quickly be at the patient's location (i.e., nursing, administration, nursing supervisors, patient advocates, etc.) to resolve the patient's complaint. A patient grievance can be a verbal or written complaint or may be submitted by email or fax that is made to the hospital by a patient, or anyone representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing complaint related to rights and limitations. A written complaint is always considered a grievance. This includes written complaints from a current patient, a discharged patient or a patient's representative." An interview was conducted with Staff #12 on the morning of 6-15-2018. Staff #12 was asked if she was aware the policy required that written complaints from current patients were always considered to be grievances and needed to be processed as such. Staff #12 stated, she had been verbally instructed by the previous CEO to process easily resolvable written complaints as complaints rather than grievances. |
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| VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING | Tag No: A0144 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of records, and interview, the facility failed to provide for a safe environment for 6 (Patient #1, #6, #7, #, 8, #9, and #13) of 13 patients reviewed. Medical equipment used in the treatment of patients presented potential risks when used in psychiatric settings. No evidence was found that risks were identified or mitigated (safety measures in place to lessen or remove the risk of harm to staff and patients) when potentially hazardous medical equipment or devices were used for patient care. Patient #9 was suicidal and had access to a ligature risks (something used for tying or binding something tightly). Ligatures can be used by a psychiatric patient to commit suicide or to choke staff or other patients. In this case, the ligature was an oxygen nasal cannula used to deliver oxygen to the patient while sleeping) and ligature attach point (a walker). Patient #13 was recently admitted after an illness, required a walker to be able to walk, and was placed on a unit with a patient (Patient #1) who was aggressive and had assaulted staff three times and destroyed property. Patient #13 got into a verbal altercation with Patient #1 while using a walker for mobility. The verbal altercation threatened to turn physical. The walker could have easily been taken away from the patient and used as weapon to harm Patient #13. Patient #13 could have used the walker as a weapon to defend himself during the verbal altercation with Patient #1. Additionally, Patient # 6, 7, and 8 were using walkers for assistance with mobility. Records did not demonstrate an identification of potential risk or consideration of mitigation to that risk. These deficient practices were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death. Findings included: Patient #9 Chart Review Patient #9 was a [AGE]-year-old female who was admitted on [DATE], involuntarily for depression and recurrent suicidal ideation. Review of physician orders were as follows: 5-5-2018 Patient was ordered to be on a level of observation every 15 minutes (which is the minimum required for all patients). Patient was ordered to be on Fall Precautions, Medical Risk, and Suicide Precautions. 5-7-2018 Patient was ordered to use oxygen at 2 liters by nasal cannula. (a nasal cannula is a slender plastic tubing that goes from the patient's face to the oxygen source). The tubing could be used as a ligature for a suicidal patient to choke themselves to death. Patient #9 was suicidal and had access to a ligature risk (something used for tying or binding something tightly). Ligatures can be used by a psychiatric patient to commit suicide or to choke staff or other patients. In this case, the ligature was an oxygen nasal cannula used to deliver oxygen to the patient while sleeping and ligature attach point (a walker). No order was found for increased monitoring. Patient #1: Review of the Patient Safety Log Active Patients showed that on: 5-27-2018, Patient #1 attacked a staff member, 5-29-2018, Patient #1 attacked a staff member, 6-1-2018, Patient #1 attacked a staff member and damaged property, 6-3-2018, Patient #1 attacked a staff member, 6-4-2018, Patient #1 attacked a staff member, 6-7-2018, Patient #1 was identified as being "out of control". Review of Pt #1's medical record revealed on 6-3-2018 at 1900, the nurse charted, "Right at shift change, pt stepped in when an agressive (sic) male pt punched our male tech in the face. (Pt#1) was up threatening the other pt. stating "I will kick your negro ass, mother fucker!" Able to have pt sit back down as he was unsteady on his feet and using a walker. He remained verbally agressive (sic), cussing and threatening harm to the aggressive (sic) pt. He states "his ass needs to go to the mother fucking jail! He been chasing these females around, talking so dirty, and acting like a piece of shit." Took him over an hour to calm down. He was demanding and rude to other staff and patients after that." On 6-14-2018, Patient #1 was observed to be shouting and threatening to the hospital staff and patients in the cafeteria. Staff #5 was able to re-direct Patient #1 away from the cafeteria. On 6-15-2018, Patient #1 was observed to be throwing his body into the door on the patient unit in an attempt to get the doors open. The patient was shouting and behaving in a threatening manner to the staff. Staff #13 was observed in the nursing station to be on his knees, supporting his upper body on the countertop. Staff #13 stated the patient had hit him "hard". Staff #9 was observed to argue with the patient about whether or not he was violent. Staff #9 stated, "You are violent and inappropriate." As the patient was starting to become more agitated, other staff members were observed to re-direct him away from the nursing station and away from the nurse who was arguing with him. Patient #13 - Review of Patient Chart Patient #13 had been admitted to the hospital on 5-10-2018 for being suicidal with a plan. Patient also expressed homicidal ideation towards a girlfriend. Physician orders on 5-11-2018 placed the patient on Suicide and Assault precautions. Level of monitoring was ordered for every 15 minutes. On 5-12-2018 the patient was ordered to be placed on Fall Precautions. No orders were found for patient to be able to use assistive devices for ambulating. Nursing notes indicate that Patient #13 was ambulating without assistance up until 5-18-2018. On 5-18-2018 through discharge on 5-22-2018, nursing notes indicate that the patient was using a wheelchair and walker for ambulation. No physician order was found for these mobility aides. No documentation was found of the consideration of risk for a suicidal/homicidal patient having equipment that could be used as weapon or used as a ligature attach point for tying off sheets or clothing used as a ligature. No documentation of mitigating actions taken for potential risks was found. Patient #13 discharged to the local medical hospital on 5-22-2018. The patient was readmitted on [DATE] with a Chief Complaint (As stated by patient): "I'm still suicidal." The physician placed the patient on Assault Precautions, Fall Precautions, and Suicide Precautions. Level of observation monitoring was every 15 minutes. Nursing notes and physician notes indicated that the patient was using a walker to aide in walking. No physician order was found for mobility aides. Patient #13 was transported back to the medical hospital the next evening and admitted for respiratory symptoms. No documentation was found in Patient #13's charts of the consideration of risk for a suicidal/homicidal patient having equipment that could be used as weapon or used as a ligature attach point for tying off sheets or clothing used as a ligature. No documentation of mitigating actions taken for potential risks was found. Review of Patient # 6, 7, and 8 showed that each patient was using a walker at some point during their stay. Records did not demonstrate an identification of potential risk or consideration of mitigation to that risk. Review of policy titled "Suicide Prevention, Policy No: CS012, Revised/Reviewed: 5/2018", and policy titled "Suicidal and Homicidal Special Precautions, Policy No: RM044, Date Reviewed 2/2018" was made. The policy for Suicide Prevention did not address the need to review any special medical equipment in use for possible hazards and adjust treatment or level of monitoring as necessary for safety. The policy for Suicidal and Homicidal Special Precautions on page 1 under Procedures state, "When admitted to the unit, the attending physician will order a degree of staff supervision and restriction from potentially harmful objects or activities consistent with the risk identified and deemed appropriate by patient's condition. The level of observation and precaution is a matter of clinical judgement. The basis for that clinical judgement should be specified in the medical record." On page 3, it states, "Security rounds should be conducted at each change of shift by the charge nurse to observe for potential safety hazards and to note the locations of each patient." The policy did not address the need to review any special medical equipment in use, or being ordered, for possible hazards and adjust treatment or level of monitoring as necessary for safety. Review of document provided titled UHS- Behavioral Health Suicide Prevention Best Practices Core Elements, under the section titled Environment states, "Provide room(s) that are as free as possible from suicide hazards by: ... Removing items that could be used for self-harm - plastic trash can liners, glass mirrors, light bulbs, curtain rods, thumb tracks (sic) on bulletin boards, electrical cords. ... Provide patients with alternative to belts and shoe laces." The document did not address the need to review current and newly ordered special medical equipment for safety risks to suicidal patients. Review of policy titled "Risk to Fall Precautions, Policy No: NS 3.14, Review Date: 5/18" was made. "PURPOSE: To reduce the number of patient falls by providing a comprehensive assessment of each patient's fall potential upon admission and throughout the patient's hospital stay. To provide assertive protective measures to minimize the risk of falls while promoting the patient's freedom of movement. Every attempt will be made to provide as much freedom to patient's as clinically permitted. PROCEDURE: ... Nursing Department ... When needed, the nurse performing this assessment will discuss with the admitting physician the need for Risk to Fall Precautions, assistive devices, and other interventions to prevent the patient from falling. The RN will initiate the physician's orders." No order for assistive devices was found. No policy identifying potential risks associated with assistive devices/medical equipment and how to mitigate the risks while equipment was in use was found. Review of Nursing Services policy, "Subject: NS 4.05, Oxygen; Review Date: June 2018" was made. The policy did not contain instructions for mitigating the risk of having a potential ligature (nasal cannula) in the possession of a psychiatric patient. Review of Nursing Services Policy, "Title: Patient Safety; Policy Number: NS 3.11; Review Date: 4/18", was made. This was found to be a one-page policy that covered medication safety and 7 points on general patient safety. The policy did not cover the potential risks associated with use of medical equipment and devices. The policy did not instruct nurses in the need to mitigate risks when potentially hazardous medical equipment and devices are used for patient care. Review of hospital policy, "Title: Organization Plan for Patient Safety; Policy No: RM029; Date Reviewed: 01/2018", was made. The hospital's organization safety plan did not address the use of medical equipment that may pose a safety risk to the psychiatric population, the need to mitigate those risks, or how to mitigate the risk when such equipment was necessary for patient care. Separate interviews were conducted with Staff #3, 15, and 16. All confirmed that special precautions were not taken for patient safety when patients were using a walker or other assistive device. Staff #3 stated that patients should be on a 1:1 (one staff member to one patient with continuous monitoring) when a patient is on oxygen with a nasal cannula. |
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| VIOLATION: STAFFING AND DELIVERY OF CARE | Tag No: A0392 | |
| Based on review of records and interview, the facility failed to ensure there was a nurse staffing plan that ensured adequate numbers of nursing staff were available to care for patients based on patient acuity, physical layout of units, availability of housekeeping or other support staff, and other factors. The facility failed to evaluate staffing concerns presented by the nursing staff. Findings were as follows: Interview was conducted with Staff #12 on 6-13-2018. Staff #12 stated, she staffed for acuity based off of the house supervisor's verbal report of staffing needs. Staff #12 stated that she did not collect or review the acuity profiles sheets that the house supervisors were supposed to fill out. She stated that those were given to Staff #3 for review. Review of staffing assignment sheets completed by Staff #12 showed that staffing was increased routinely when patients were ordered to have 1 staff to 1 patient (1:1) monitoring. An interview with Staff #3 was conducted on 6-13-2018. When asked about staffing for acuity of patients and other factors, Staff #3 stated, the house supervisors filled out a form titled "Glen Oaks Hospital Acuity Profile". Staff #3 was asked to provide the acuity profile forms from April 1, 2018 through June 12, 2018. When the forms were provided, it was noted that forms were missing for many dates. Staff #3 checked with the individual house supervisors, in the house supervisor's office, and with the staffing coordinator to ensure no other forms were kept elsewhere. No other forms were provided. The forms had a signature line for the house supervisor to sign, date, and time. There was also a line for a "Reviewed by" signature and date. Staff #3 stated she was the person who reviewed them, but did not sign and date any of the forms when she reviewed them. Review of forms showed that there were 146 shift that should have had an acuity profile form completed for each unit with patients on it. Only 56 shifts had profile forms completed, leaving 90 shifts with no evidence that patient acuity was considered in staffing. Staff #3 was asked to provide a copy of the nurse staffing plan. Staff #3 initially stated, she did not have a staffing plan. Staff #3 stated, she staffed to the grid. Staff #3 stated she monitored staffing to the grid for her quality reporting. Staff #3 provided a copy of her Process Improvement (PI) monitor showing that "In November (2017) audits revealed the nursing units were not staffed to grid 100% of the time." The bar graphs on the monitor form showed that the third quarter of 2017, staffing to minimum grid was at 99%. Fourth quarter of 2017 was at 100%. First quarter of 2018 had dropped to 98%. The monitor does not address staffing for acuity. Review of the Hospital Quality Council Meeting minutes for March 2018, April 2018, and May 2018 showed that the nursing department was reporting information on staffing to the minimum staffing grid. Topic for discussion in March 2018 was: "Under grid 3 time throughout February," "Numerous call-ins and errors on the daily sheets," and "Several vacancies in the nursing department". Action/Status was: "Continued education with house supervisors and staff on the staffing grid and how to properly staff units. Continue to hire PRN (as needed) Nurses and MHT's (Mental Health Technicians) to build PRN pool. Staffing coordinator calling and confirming census at least twice daily and reconciling staffing from there. DON (Director of Nursing) holding staff accountable for excessive call ins." Topic for discussion in April 2018 was "For the month of March there were a total of 33 call ins. 22 during the week, 11 on the weekend. House supervisor had to cover a shift 6 times and staffing coordinator had to cover 3 shifts" Action/Status was "Continued education with house supervisors and staff on the staffing grid and how to properly staff units. Continue to hire PRN (as needed) Nurses and MHT's (Mental Health Technicians) to build PRN pool. Staffing coordinator calling and confirming census at least twice daily and reconciling staffing from there. DON (Director of Nursing) holding staff accountable for excessive call ins." The Action/Status was the same for both months. Factors to decide on adequate staffing levels other than census were not discussed in the minutes of the meeting. Topic for discussion in May 2018 was "In the month of April 2018 there were 25 call ins. 12 MHT, 1 LVN (licensed vocational nurse), and 12 RN (registered nurse). Of the call ins 8 were a weekend shift, 17 week day shifts, 17 day shift and 8 night shift. Many new PRN nurses hired on and finishing their on the job training will now be able to help fill call ins and shorthanded shifts." (sic) Action/Status was "Need to hire PRN MHT's to build the PRN pool to help decrease overtime and assist with finding coverage when there are call ins and on to ones. Start tracking per patient days moving forward." No discussion was found in the minutes of the quality meeting about staffing shortfalls due to increased patient acuity other than needing MHTs for patients who had been ordered to have 1:1 monitoring. Later in the day, Staff #3 provided a one-page policy titled Nurse Staffing Plan with a review date of 6/18. Staff #3 stated she had forgotten that she had just updated this policy. The policy was as follows: "SCOPE: All employees who work in the Nursing Services Department including RNs, LVNs, and MHTs. POLICY: It is the policy of Glen Oaks Hospital that the nursing staff will be scheduled according to patients' needs and will provide a safe and effective milieu. PROCEDURE: 1. Schedules for nursing staff are completed by the Staffing Coordinator or designee, and posted in Shifthound (the electronic staffing app) for staff information for at least one month 2. The nursing department employs licensed RNs, LVNs, and unlicensed MHTs (mental health techs). These personnel work shifts of 12 hours in a given day. These personnel also work in various statuses of full-time, part-time, and PRN (as needed). 3. Whenever any unit has patients, an RN will be present on that unit. Whenever any unit has patients, there will be scheduled a minimum of 1 nurse and 1 MHT. 4. As the patient load on a unit varies with admissions and discharges the nursing staff will be flexed accordingly. 5. When the acuity of the milieu on a given unit becomes increasingly severe, the Director of Nursing utilizing professional judgement and the acuity system, will determine adequate staffing increases to accommodate. An additional MHT may be scheduled when a patient needs 1:1 observation, Q5 minute checks, or HSl observation for patient safety." Review of the Nurse Staffing Committee meeting-minutes binder revealed that in 2014 there was a 5-page Nurse Staffing Plan that encompassed all areas necessary in a nurse staffing plan to include elements such as: 1. Number of beds staffed. 2. Patient population served. 3. Orientation of new staff. 4. Procedures for calling in staff or placing staff on call. 5. Elements other than census that affect need for additional staffing. 6. Each unit and factors such as geographic of the unit that may affect staffing. 7. Identified areas where nursing care is delivered. 8. Identification of patient's nursing care needs. 9. Nurse care activities. 10. Delegation of nursing tasks. 11. Interdepartmental functioning. 12. Schedule for regular nursing plan review. The plan in the binder was a working copy with handwritten notes that demonstrated that the Nurse Staffing Advisory Council had been actively updating the plan at that time. Staff #3 stated she did not know that was in the binder and had never seen it Minutes to the March 29, 2018 Staffing Advisory Committee meeting were reviewed. Nursing staff reported that they felt unsafe on the Stabilization Care Unit (SCU) when it is staffed with one RN and one MHT and there are only "little women" on the unit. The SCU patients were the highest acuity patients, needing stabilization prior to going to the other units. Some of the concerns included not having float staff to relieve staff for breaks, not having float staff to help with peak admission and discharges, not having enough time to complete charting or do proper skin searched at admission, the disruption to continuity of patient care if MHTs are moved to 8 hour shifts and nurses are on 12 hour shifts, and concerned that patients being admitted from the Dallas area "are more risky(sic) and aggressive". "They need more supervision. The website says GOH is a 'comfy home environment' but it now more like a prison." The Action/Status documented in the meeting minutes for these concerns, and others, was: "75% RN's present, with 1 LVN and 2 MHT's". No evidence was provided that any of the concerns expressed by the nursing staff were evaluated or followed up on by Nursing or hospital administration. No evidence that their concerns were discussed in the Quality Council or Patient Safety Council. During separate interviews with Staff #3, Staff #15, and Staff #16, all indicated that there was an increase in aggressive patients. During an interview with Staff #1, he indicated that it was just staff perception and that there was no proof that patients being admitted were more aggressive. No evidence of any type of analysis of patient aggression related to the new patient population being admitted from Dallas was presented to show that the facility had evaluated nurse staffing concerns regarding staffing needs in relation to increases in aggressive patients. Patient Safety Council Report for the month of March 2018 revealed that the hospital was below the benchmark for incidents of patient aggression with and without injuries. Review of April and May 2018 Patient Safety Council Reports revealed that the hospital was above the benchmark for incidents of patient aggression with and without injuries. No analysis of the change was provided in the meeting minutes. The Problem Statements, Process Expectations, Process Implementation Plan, and Process Solution were the same for all three months for both categories (Patient Aggression - with no injury / Patient Aggression - with injury). "Problem Statement: No serious injuries reported." "Process Expectations: Direct care staff are trained upon hire and annually for handle with care and verbal de-escalation." "Process Implementation Plan: HR monitors for compliance with training of handle with care and verbal de-escalation. Staff training for verbal de-escalation began 2/9/2015." "Process Solutions: Monitored by risk management via HPR and reported monthly to PSC." |
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| VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES | Tag No: A0749 | |
| Based on review of records and interview, the facility failed to: A. develop effective policies and nursing staff training for the safe transfer of potentially infectious linens and towels from an infected patient's room to dirty laundry storage. Linens and towels that were potentially contaminated with infectious organisms were openly transported down the hallway from the patient's room to the dirty laundry storage area. This practice potentially exposed other patients and staff to infectious organisms. B. properly document Tuberculosis Skin Test (TST) administered in 10 (Staff #s 3, 6, 7, 8, 9, 10, 11, 13, 14, and 17) out of 10 employee health files reviewed. TST administrations and results readings were recorded with dates only and not with time. TST is a time-sensitive test that cannot be read 48 prior to or 72 hours after administration. This practice failed to ensure the accuracy of the test results and could allow for potentially infected staff to be working with patients. Findings for item A: Staff #15 was interviewed on the morning of 6-14-2018. Staff #15 stated that nursing staff were required to remove linen and towels from the patient rooms, down an open hallway that other staff and patients used, to the dirty laundry storage area. Staff #15 stated that nursing staff had been told they were not to take plastic bags onto the unit that contain soiled linens. Staff #15 stated that patients frequently had skin infections or other sexually transmitted diseases and believed the practice to be a risk to staff and patients. After the soiled linens and towels were placed in a contained bin, housekeeping staff would remove the potentially contaminated linens and towels from the unit to be picked up by the contracted company for processing. Staff #3 was interviewed on the morning of 6-14-2018. When asked if the previous day's video needed to be reviewed to confirm this practice, Staff #3 stated, "No. That's the process." When asked if nursing staff received any specialized training on the handling of clean and dirty linens, Staff #3 confirmed there was not any additional training provided. Staff #5 was interviewed the afternoon of 6-14-2018. Staff #5 confirmed that housekeeping staff was provided with training specific to handling contaminated linen and towels. Staff #5 stated that this training was not provided to nursing staff. Review of the Infection Control Report for the first quarter of 2018 showed that there were 165 patients during the months of January, February, and March who had identified infections. The report identified that 7 of those infections were hospital acquired. Review of policy, Title: Handling and Transport of Soiled Linen; Policy No: ICH011; Revised: 01/2018 was as follows: "POLICY: All used linen will be considered contaminated and is handled in such a manner as to minimize microbial contamination. PROCEDURE: The employee will: Place soiled linen inside covered linen cart which is lined with a blue bag. Linen cart is kept in unit laundry rooms. Avoid shaking or unnecessary motion when handling soiled linens which may cause a dispersal of organisms. Not allow linen to touch the floor or place dirty linen on the floor. Wear appropriate protective garb if linen is wet (e.g., gloves, gowns where applicable). Keep linen hamper covered. Replace blue plastic linen bag in hamper when full. Environmental services staff will remove soiled linens from laundry rooms daily." Review of training files for nursing Staff #'s 6, 9, 10, 11, 12, 13, and 14 confirmed that no documented training or competency for the handling of soiled linens in a safe manner was found. Findings for item B: On the morning of 6-15-2018, employee health files were reviewed. The form used contained an employee signature line and a date line. No line for "Time" was found on the form. The employee was signing as acknowledgment of the following statements: "I understand that the results of this test will be kept confidential. I have been informed of the symptoms of Tb and the contraindications of taking the Tb skin test. I AGREE TO HAVE THIS TEST READ WITHIN 48-72 HOURS." There was a line "Given by:" for the name of the staff member administering the TST. There was not a date or time line for the staff member to indicate the date and time the test was actually administered. The "Date read:" and a "Read by:" lines were below the "Given by:" line. There was not a "Time read:" line on the form. Staff #2 was interviewed on the morning of 6-15-2018. Staff #2 confirmed that results were not valid if read prior to 48 hours from administration. Staff #2 confirmed that results were not valid if read past 72 hours from administration. Staff #2 confirmed that it was not possible to determine if the tests had been read within the 48 to 72-hour window based on the documentation provided. Review of policy, Title: Tuberculosis Testing of Employees; Policy No: ICE001; Revised: 01/2018, did not include instructions for documenting the time of administration and time of result reading to verify that the test had been properly read within the specified time frame. |
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