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.
| EASTERN IDAHO REGIONAL MEDICAL CENTER | 3100 CHANNING WAY IDAHO FALLS, ID 83404 | June 14, 2019 |
| VIOLATION: PATIENT RIGHTS: GRIEVANCES | Tag No: A0118 | |
| Based on patient rights and responsibilities information review and staff interview, it was determined the hospital failed to ensure patients were informed of how to file a grievance with Idaho SA. This lack of information had the potential to prevent patients from filing grievances regarding their care. Findings include: A patient rights and responsibilities brochure, which is provided to patients and their representatives, included information on how to file a grievance with the contracted QIO, accrediting body, OCR, and hospital. The brochure did not include information on how patients and their representatives could file a grievance with the Idaho SA. The Patient Advocate was interviewed on 6/13/19, beginning at 9:45 AM, and the patient rights and responsibilities brochure was reviewed in her presence. She confirmed the brochure did not include information on how patients and their representatives could file a grievance with the Idaho SA. The hospital failed to inform patients and their representatives how to file a grievance with the Idaho SA. |
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| VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES | Tag No: A0122 | |
| Based on hospital grievance response letter review and staff interview, it was determined the hospital failed to ensure patients were informed of the time frame for review and response to grievances. This impacted all patients who had filed a grievance with the hospital and had the potential to interfere with understanding of the grievance process. Findings include: Initial response letters to patient grievances which required additional time to investigate were reviewed. All initial response letters issued by the hospital followed a pre-formatted template which stated the hospital would require, "additional time to complete." However, the template did not include a time frame for this additional grievance response. The Patient Advocate was interviewed on 6/13/19, beginning at 8:29 AM, and the hospital's initial grievance response template was reviewed in her presence. She confirmed the template did not include a time frame for the grievance response. The Patient Advocate stated a time frame would be added to the template immediately. Patients were not informed of the time frame for review and response to their 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 medical record review, observation, education materials review, document review, policy review, and staff interview, it was determined the hospital failed to ensure staff were trained and competent to operate emergency equipment. Additionally, the hospital failed to ensure suicide precautions were followed for 1 of 1 patient (Patient #3) who was a minor with SI and whose record was reviewed. These issues had the potential for care to be provided in a setting which was unsafe. Findings include: The hospital failed to ensure care in a safe setting. Examples include: 1. A tour of the hospital's ASU was conducted on 6/12/19, beginning at 8:15 AM, in the presence of the Unit Manager. Eight beds in the ASU [3rd floor] were currently occupied by 4th floor [step-down] overflow patients. A 4th floor RN, who had floated to the ASU to care for the 4th floor overflow patients, was interviewed on 6/12/19, beginning at 8:19 AM. When asked how non-ambulatory patients would be evacuated to the lower hospital floors in the event of a fire, the RN stated a stair-chair [Stryker Evacuation Chair] would be used. When asked if he could locate a stair-chair in the ASU, he stated he could not. When asked if she could locate a stair-chair in the ASU, the Unit Manager stated she could not. At that point, it was discovered the ASU floor did not have a stair-chair. The closest unit to have a stair-chair was located in an adjacent building separated by a long hallway. A tour of the hospital's 2nd floor was conducted on 6/12/19, beginning at 3:00 PM, in the presence of the Stroke Program Manager and ICU Director. During the tour, an ICU RN was interviewed and asked to locate a stair-chair for use in a fire emergency. One stair-chair was located, however, the RN was unable to operate it. When asked if she could operate the stair-chair, the ICU Director stated, "no." The ICU Director stated she had trained to use the stair-chair, "one time a long time ago." A tour of the hospital's 6th floor was conducted on 6/13/19, beginning at 1:10 PM, in the presence of the Stroke Program Manager. During the tour, the 6th floor CN was interviewed and asked to locate a stair-chair for use in a fire emergency. Two stair-chairs were located; however, the CN was unable to operate either. When asked if she had received training on how to operate the stair-chair, the CN stated she believed she had, "last year." A tour of the hospital's 4th floor was conducted on 6/13/19, beginning at 1:26 PM, in the presence of the Stroke Program Manager. During the tour, a 4th floor CNA was interviewed and asked to locate a stair-chair for use in a fire emergency. One stair-chair was located in an equipment storage room, located in the back-left corner, blocked by numerous large pieces of patient care equipment. When asked if she was able to operate the stair-chair, the CNA stated, "no, I never received training." A blank "EIRMC FIRE DRILL" form was requested and reviewed. The form included several actions for staff to complete in the event of a fire. The form did not include locating and operating a stair-chair for emergency patient evacuation in the event of a fire. Stair-chair education and training were requested. An email with a picture of the Stryker Evacuation Chair was provided with the words "Annual training - Safety Exam" handwritten at the top. The email did not include a safety exam or instructions on how to use the stair-chair. The email did not include a staff roster of who had participated in the training. The Director of Patient Safety was interviewed on 6/12/19, beginning at 5:01 PM. When asked if stair-chairs were included on daily emergency equipment checks by hospital staff, she stated, "no." The Director of Patient Safety confirmed the observational findings on staff's inability to locate and safely operate stair-chairs in the event of an emergency. The hospital failed to ensure staff were educated and trained on the use of emergency equipment in the event of a fire. 2. The hospital's policy, "Patient Safety Attendant for Patient Observation (Sitter)," effective 3/14/19, stated, "A patient who has demonstrated that they are at risk for harm to self, others or property, and have not responded to alternative methods of care will be continually visually observed by a PSA until the Clinical Nurse Supervisor/House Supervisor/Designee determine that the patient is no longer at risk and/or obtains a Physician order that suicide risk has been removed." The policy included "ADDENDUM A, Patient Safety Attendant (PSA) Guidelines/Responsibilities/Competencies." The addendum stated, "The PSA will document the patients' continuous observation on a designated paper flow sheet every 15 minutes for Suicidal/High Risk patients and every 30 minutes for Safety Risk patients. The flowsheet is a permanent part of the medical record and must be signed off by the RN each shift." This policy was not followed. An example includes: Patient #3 was a [AGE] year old male admitted on [DATE], following a suicide attempt. He was transferred from the PICU to the BHC on 4/30/19. His PICU record was reviewed. Patient #3's record included a physician's order for suicide precautions, dated 4/28/19. Patient #3's record included an RN shift assessment, dated 4/28/19 at 9:30 PM. The assessment stated he was at risk for suicide, as evidenced by his recent suicide attempt and "seeking ways to harm self." The assessment stated a sitter was at Patient #3's bedside. Patient #3's next RN shift assessment was documented on 4/29/19 at 8:00 AM. It did not include a suicide risk assessment. It stated a sitter was at Patient #3's bedside. Patient #3's record included a "Behavior Health Assessment," dated 4/29/19 at 1:31 PM, signed by a Psychiatric Technician. It stated Patient #3 was at risk for suicide and documented the warning signs "Seeking ways to harm self" and "Current plan [with] lethality." Patient #3's next RN shift assessment, dated 4/29/19 at 8:40 PM, included a suicide risk assessment. It did not state Patient #3 had a sitter. There was no physician's order or documented determination by a supervisor to discontinue the sitter. Patient #3's record did not include a flow sheet with documentation of continuous observation by a sitter every 15 minutes as required per hospital policy. It could not be determined from his record if a sitter was provided for his safety during his entire stay on the PICU. The Division VP of Nursing Operations was interviewed on 6/13/19 at 2:15 PM, and Patient #3's record was reviewed in her presence. She stated a suicide risk assessment was a required component of each RN shift assessment, and confirmed it was not completed as part of Patient #3's RN day shift assessment on 4/29/19. The Division VP of Nursing Operations confirmed there was no PSA flow sheet to document continuous observation of Patient #3. She stated the PSA policy, addendum, and flow sheet were effective 3/14/19, but had not been implemented by the hospital at the time of Patient #3's PICU admission, 4/28/19 to 4/30/19. The hospital failed to ensure Patient #3's safety by performing suicide risk assessments every shift and providing a PSA during his entire PICU stay. |
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| VIOLATION: PATIENT SAFETY | Tag No: A0286 | |
| Based on hospital policy review, job description review, restraint log review, security log review, review of incident reports, and staff interview, it was determined the hospital failed to ensure adverse events documented in security logs were identified and analyzed. Additionally, the hospital failed to ensure restraints applied by armed and unarmed hospital security staff on patients were identified and analyzed. This had the potential for unidentified adverse patient events and incomplete quality data used to analyze patient care. Findings include: 1. A hospital job description "Security Officer - Armed," revised 2/2019, stated, "This position requires logging of daily tasks, conducting thorough investigations and completing detailed incident reports." A hospital policy "Occurrence Reporting," effective 9/11/18, stated, "Meditech is the HCA-designed system used to report events and close calls and should be available to all staff." An armed security officer was interviewed on 6/11/19, beginning at 2:46 PM. When asked if he submitted hospital incident reports, he stated, "yes." When asked if he had access to the hospital's EMR system to enter incident reports, he stated, "no." The hospital's armed security officer log from 4/01/19 through 6/09/19, was reviewed. An entry dated 4/08/19 at 7:03 PM, by an armed security officer, stated, "I completed a an [sic] IFPD case report along with an EIRMC Incident Report [sic]. The incident report was placed in the basket." The hospital incident report log from 1/01/19 to 6/10/19, was reviewed. All incident report entries documented in the log had been entered into the hospital's EMR system, Meditech. It was unclear if the incident report log included incidents generated by armed and unarmed hospital security officers. The Director of Plant Operations and Security was interviewed on 6/13/19, beginning at 4:02 PM. He stated he was the hospital's supervisor for armed and unarmed security services. When asked if armed and unarmed hospital security officers had the ability to enter incident reports in Meditech, he stated, "no." When asked if armed security officers were employees of the hospital, The Director of Plant Operations and Security stated, "yes." He stated unarmed hospital security officers were contracted and also did not have access to Meditech. The Director of Plant Operations and Security stated armed and unarmed hospital security officers would submit incident reports via their own paper reporting system. When asked if the paper incident report forms used by armed and unarmed hospital security officers had been vetted and approved by the hospital's Governing Body, the Director of Plant Operations and Security stated, "no." When asked if the hospital's QAPI program identified and analyzed armed and unarmed hospital security incident reports, the Director of Plant Operations and Security stated, "no." The Director of Plant Operations and Security confirmed the job description for armed hospital security officers conflicted with hospital policy in regard to their ability to enter incident reports. Hospital security incident reports were not identified and analyzed by the hospital's QAPI program. 2. The hospital's armed security officer log from 4/01/19 through 6/09/19, was reviewed. The log included 4 entries by armed hospital security staff who documented applying patient restraints: a. 4/01/19 at 2:00 PM: "...They needed help to restrain her while they gave the medication. Myself and [unarmed hospital security] restrained her while medication was administered. She didn't fight while we were restraining her. Once medication was given she was released." b. 4/10/19 at 4:50 AM: "...I restrained her with a straight arm bar [sic] and escorted her back to room 3." c. 4/28/19 at 8:35 PM: "Male that was highly agitated was given medication. A cathator [sic] was placed and he became upset. I held his legs as he got agitated so he would not kick staff." d. 5/31/19 at 6:00 PM: "Assisted medical in holding down intoxicated suicidal pt while they obtained blood and urine. I stood by until she calm [sic] down." The hospital restraint log from 1/01/19 to 6/11/19, was reviewed. All restraint entries documented in the log had been entered into the hospital's EMR system, Meditech. The 4 examples above were not documented on the hospital restraint log. The Director of Plant Operations and Security was interviewed on 6/13/19, beginning at 4:02 PM. When asked if armed and unarmed hospital security officer patient restraints were documented in the hospital's restraint log, he stated, "no." When asked if the hospital's QAPI program identified and analyzed armed and unarmed hospital security restraints, the Director of Plant Operations and Security stated, "no." Patient restraints applied by hospital security staff were not identified and analyzed by the hospital's QAPI program. |
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| VIOLATION: NURSING CARE PLAN | Tag No: A0396 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital policy review, and staff interview, it was determined the hospital failed to ensure a thorough nursing care plan was developed for 1 of 2 Postpartum patients (Patient #42) whose care plans were reviewed. Lack of a complete care plan had the potential for unmet patient needs. Findings include: The hospital's policy, "Interdisciplinary Care Planning Process," dated 4/16/19, stated, "[The facility] ensures that care is planned to respond to each patient's unique needs (including age-specific needs), expectations and characteristics with effective, efficient and individualized care based on needs identified in the assessment process ... The care planning process identifies goal for care, treatment and rehabilitation in the most appropriate setting with services required to meet the goals." This policy was not followed. An example includes: Patient #42 was a [AGE] year old female admitted on [DATE], for a cesarean section. Her diagnoses included pregnancy induced hypertension, gestational diabetes, and pre-eclampsia. Patient #42's medical record included a care plan, initiated at the time of admission to the Postpartum unit on 6/08/19. It did not include interventions or goals for pre-eclampsia. The Women's Center Director and the Postpartum Unit Charge RN were interviewed together on 6/12/19 at 9:00 AM. They confirmed Patient #42's care plan did not include interventions or goals for pre-eclampsia. The hospital failed to ensure a care plan was developed to address care for Patient #42's diagnosis of pre-eclampsia. |
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| VIOLATION: CONTENT OF RECORD - INFORMED CONSENT | Tag No: A0466 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and hospital policy, and staff interview, it was determined the hospital failed to ensure written consent forms for admission and treatment were properly executed for 3 of 3 pediatric patients (#2, #3, and #60) whose records were reviewed. This had the potential for minors' treatment being provided without the consent of their legal representative. Findings include: The hospital's policy, "Consent for Treatment," effective 7/12/18, stated, "EIRMC requires that written consents for treatment be obtained and made a part of the patient's medical record...when the patient is a minor, either the parent(s) or an appropriately designated legal guardian must give consent to medical treatment." 1. Patient #3 was a [AGE] year old male admitted on [DATE], following a suicide attempt. He was transferred from the PICU to the BHC on 4/30/19. His PICU record was reviewed. Patient #3's record included a "Conditions of Admission and Consent for Outpatient Care," dated 4/28/19. The form included a section titled, "Patient/Patient Representative Signature," that included a signature. The section stated, "If you are not the Patient, please identify your Relationship to the Patient. (Mark relationship(s) from List below): Patient." Patient #3 was a minor and unable to consent to care. It could not be determined who signed his consent form. The Director of Quality was interviewed on 6/14/19 at 7:55 AM. She reviewed Patient #3's consent form and confirmed it did not state who signed the form to give consent for his care. Patient #3's consent form did not accurately state who gave consent for his hospital care. 2. Patient #2 was a 7 year old male admitted on [DATE], with a diagnoses of [DIAGNOSES REDACTED] Patient #2's record included a "Conditions of Admission and Consent for Outpatient Care," dated 6/07/19. The form included a section titled, "Patient/Patient Representative Signature," that included a signature. The section stated, "If you are not the Patient, please identify your Relationship to the Patient. (Mark relationship(s) from List below): Patient." Patient #2 was a minor and unable to consent to care. It could not be determined who signed his consent form. The Director of Quality was interviewed on 6/14/19 at 7:58 AM. She reviewed Patient #2's consent form and confirmed it did not state who signed the form to give consent for his care. Patient #2's consent form did not accurately state who gave consent for his hospital care. 3. Patient #60 was a [AGE] year old female admitted on [DATE], with a diagnosis of [DIAGNOSES REDACTED] Patient #60's face sheet stated she was admitted on [DATE] at 1:03 PM. Her record did not include a consent for treatment. The consent was requested, and documentation was provided that stated, "PARENTS NOT HERE TO SIGN COA'S [Conditions of Admission]." The documentation was dated 4/12/19 at 10:47 AM. Patient #60's record included documentation signed by the Child Life Specialist, dated 4/11/19 at 1:10 PM, 7 minutes after her admission. It stated "Specialist met with: Parent." It could not be determined why consent for admission was not obtained from Patient #60's parent at that time. The Director of Quality was interviewed on 6/14/19 at 8:00 AM. She stated Patient #60 was a "direct admit" to the pediatric floor, and the Registrar went to the floor the following day to obtain consent for admission. Patient #60's parents were not present at that time. The Director of Quality stated the Registrar should have made another attempt to get the consent signed and confirmed there was no documentation of an additional attempt. She confirmed Patient #60's record did not include consent for her hospital services. The hospital failed to obtain consent for admission for Patient #60. |
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| VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES | Tag No: A0749 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital document review, observation, hospital policy review, AORN guidelines review, ASHRAE standards review, and staff interview, it was determined the hospital failed to ensure clinical staff followed effective infection control practices, including hand hygiene, and identified potential infections for patients and personnel. This had the potential for inadequate interventions to mitigate environmental and surgical infection risks. Additionally, the facility failed to demonstrate specific parameters of a water management program for waterborne pathogens such as Legionella. Failure to consider the ASHRAE industry standards and utilize parameters defined in the CDC toolkit, has the potential to limit relevant facility awareness and expose residents to Legionella and other opportunistic waterborne pathogens based on incomplete or inconclusive data. This deficient practice could potentially affect all patients and staff on the dates of the survey. Findings include: 1. During review of provided policies and procedures for water management on June 11, 2019, from approximately 8:00 AM to 11:00 AM, records demonstrated the facility had not completed a comprehensive facility risk assessment, taking into consideration risks identified in ASHRAE industry standards and the parameters defined in the CDC toolkit for developing a water management program. Additionally, the facility had not identified acceptable ranges for control measures or documented testing protocols. Interview of the Director of Facilities and Facility Safety Coordinator revealed the facility was unaware the current water management plan was lacking required components. 2. A hospital policy "Hand Hygiene," effective date 3/04/19, stated: - "Perform hand hygiene using alcohol hand rub or handwashing before planned and unplanned (room entry) patient contact & after contact with patient or patient's environment (room exit)." - "Decontaminate hands if moving from a contaminated body site to a clean body site during patient care." - "Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient." - "Decontaminate hands after removing gloves." A policy for the disinfection of the IMoblie devices [hospital-provided cell phones utilized by clinical staff] was requested. The Hospital provided a document titled "2015 mobile Device Cleaning and Disinfection Guidelines" undated. The document stated: - "Devices should be regularly disinfected between use in patient rooms or care areas to reduce the risk of transmission." - "If the mobile device was in use or accessed while in a patient's room, sanitize the device before removing gloves." These 2 policies were not followed. Examples include: a. Patient #39 was a [AGE] year old female, admitted on [DATE], for multiple trauma post motorcycle crash. Additional diagnoses included spleen laceration, liver laceration, and fractured femur. On 6/11/19 at beginning at 1:45 PM, an RN was observed administering medications to Patient #39. Upon entering her room, the RN did not perform hand hygiene prior to donning gloves. After the RN administered Patient #39's medications she retrieved the facility provided IMobile device from her pocket, sent a message, and placed the device back in her pocket. The RN removed her gloves, performed hand hygiene, and left Patient #39's room. The RN did not perform hand hygiene prior to donning gloves and did not disinfect her IMobile device after using it with gloved hands in the patient room. During an interview with the Director of Patient Safety and the RN on 6/11/19 beginning at 3:10 PM, the RN confirmed she did not perform hand hygiene prior to donning gloves. The Director of Patient Safety confirmed the RN should have disinfected the device after use in Patient #39's room per policy. The RN failed to perform hand hygiene per policy and disinfect her device per policy. b. A colonoscopy procedure was observed on 6/12/19 from 1:39 PM to 2:30 PM on the GI unit. During the procedure, the following infection control issues were noted: i. An RN was observed wearing gloves while using a computer keyboard then handling a specimen container which she placed next to the endoscopy tech. The RN did not cleanse her hands or change gloves after using the keyboard and handling the specimen container. ii. The CRNA was observed pen to document then handling the patient's IV port and medication syringes. The CRNA did not cleanse his hands or change gloves after using the pen and handling the patient's IV port and syringes. The Chief Medical Officer and the Director of Quality were interviewed together on 6/13/19 beginning at 1:00 PM. They confirmed the observed actions did not follow their hand hygiene policy. iii. During an observation of endoscope reprocessing, an endoscopy tech was observed placing an unprocessed endoscope into an automated reprocessor, then removing a processed endoscope from another automated reprocessor, and opening the endoscope storage cabinet. The Chief Medical Officer and the Director of Quality were interviewed together on 6/13/19 beginning at 1:00 PM. They confirmed the observed actions did not follow their hand hygiene policy. 3. Patient #53 was a [AGE] year old female who was admitted on [DATE], for left elbow surgery. Her surgical procedure was observed. She was discharged on [DATE]. The following infection control breaches were identified during the observation of Patient #53's surgical procedure on 6/12/19, from 8:58 AM to 9:47 AM: a. A hospital policy "OR - OR - Hand Hygiene in the Perioperative Setting," effective 8/11/16, stated, "Perform hand washing...Before putting on gloves and after removing gloves or other personal protective equipment (PPE)." This policy was not followed. At the conclusion of Patient #53's surgical procedure at 9:36 AM, the circulating RN, while wearing gloves, removed several pieces of blood-soaked gauze from a floor basin, and placed them into individual pouches to be counted. The circulating RN performed this task twice with the same soiled gloves. The circulating RN, while continuing to wear the same soiled gloves, touched and manipulated several patient care items in the OR suite. The circulating RN removed his gloves and exited the OR suite at 9:39 AM, but did not perform hand hygiene. b. A hospital policy "OR - Surgical Environment," effective 6/22/15, stated, "Eating, drinking and the handling of personal and personal care items (i.e., the application of lip balm, cell phones, etc.) is prohibited within the operating rooms and areas beyond the red line." This policy was not followed. AORN Guidelines 2015, "Clean surgical attire should be worn in the semi-restricted and restricted areas of the perioperative setting, Recommendation I.m," states, "Cell phones, tablets, and other personal communication or hand-held electronic equipment should be cleaned with a low-level disinfectant." This guideline was not followed. The CRNA pulled a cell phone from his pocket at 9:26 AM with ungloved hands, manipulated the cell phone, and placed the cell phone back in his pocket. He did not perform hand hygiene before or after touching the cell phone. It was unclear how the CRNA's cell phone was sanitized for the OR setting. c. AORN Guidelines 2015, "Personnel entering the semi-restricted and restricted areas should cover the head, hair, ears, and facial hair, Recommendation III.a," states, "A clean surgical head cover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of neck should be worn." This guideline was not followed. The surgeon, surgical first assist, scrub nurse, surgical nurse, and CST all wore a surgical head cover which left their ears fully exposed; especially pertinent for those surgical staff directly above the sterile surgical site and sterile surgical equipment. d. Several OR suite horizontal surfaces, approximately greater than 6 feet in height, had a visible layer of dust. This included the wall clock and several ceiling-suspended boom-arms in the periphery of the suite. The Director of Surgical Services was interviewed on 6/12/19, beginning at 10:30 AM, and Patient #53's OR suite observations were reviewed in his presence. When asked what infection control guidelines governed staff in the surgical setting, he stated, "AORN." The Director of Surgical Services confirmed surgical staff did not follow hospital policy and AORN guidelines in regards to observed infection control breaches. Hospital surgical staff failed to follow hospital infection control policy and AORN guidelines. 4. Patient #60 was a [AGE] year old female admitted on [DATE], for a colonoscopy. Her procedure was observed on 6/12/19 from 1:39 PM to 2:30 PM on the GI unit. During the procedure, the following infection control issues were observed: a. An RN was observed wearing gloves while using a computer keyboard then handling a specimen container which she placed next to the endoscopy tech. The RN did not perform hand hygiene or change gloves between using the keyboard and handling the specimen container. b. The CRNA was observed using a pen to document, then handling the patient's IV port and medication syringes. The CRNA did not perform hand hygiene or change gloves between using the pen and handling the patient's IV port and syringes. 5. During an observation of endoscope reprocessing, an endoscopy tech placed an unprocessed endoscope into an automated reprocessor then, without performing hand hygiene or changing gloves, removed a processed endoscope from a different automated reprocessor. The Chief Medical Officer and the Director of Quality were interviewed together on 6/13/19, beginning at 1:00 PM. They confirmed the observed actions did not follow their hand hygiene policy. |
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| VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN | Tag No: A0820 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of medical records, hospital policies, grievance log, and staff interviews, it was determined the hospital failed to prepare patients for post hospital needs for 2 of 2 patients (#1 and #6) whose records were reviewed for discharge planning. This resulted in patients being discharged without having the knowledge and ability necessary to meet their post-hospitalization needs. Findings include: The hospital's policy, "Discharge Planning" effective 5/02/19, stated, "A multidisciplinary team approach will be utilized to develop a plan to include the patient, family, and significant others as applicable, working together with the healthcare team. The healthcare team will include disciplines with specific expertise as indicated by the needs of the patients." This policy was not followed. Examples include: 1. Patient #6 was a [AGE] year old female admitted on [DATE], and discharged on [DATE]. During her admission, she had abdominal surgery that resulted in a colostomy. Her record was reviewed for case management and discharge planning services. The hospital's grievance log was requested and reviewed. It included a grievance submitted by a home health RN who completed Patient #6's home health admission assessment following her discharge from the hospital. The grievance stated Patient #6 lived alone and was not able to take care of her colostomy due to arthritis, with "Cracked, bleeding and swollen hands." Additionally, it stated Patient #6 did not have colostomy supplies in her home. Patient #6's record included a "Wound Team" note, dated 10/15/19, signed by an RN. The note stated the RN changed Patient #6's colostomy bag and "PATIENT WAS WALKED THROUGH THE CHANGE." It stated, "I WILL CONTINUE TO FOLLOW AND EDUCATE." Patient #6's record included a "CASE MANAGEMENT REPORT," dated 10/16/19, signed by a Case Manager. The note stated Patient #6 was to be discharged that day, and home health services were set up. It stated an order was sent to an equipment company for a walker. The note did not reference Patient #6's colostomy or her ability to complete colostomy care. It did not reference colostomy supplies or how Patient #6 would obtain them. The wound care RN was interviewed on 6/13/19 at 3:35 PM. She stated she saw Patient #6 on 10/15/18, and began teaching her to care for her colostomy. The wound care RN stated she planned to provide further education and send her home with colostomy supplies. She stated she was not aware Patient #6 was being discharged on [DATE]. The wound care RN stated she was not included in Patient #6's discharge planning, and her discharge planning was not completely appropriately. The Director of Case Management was interviewed on 6/13/19 at 2:15 PM. She confirmed there was no documentation of Patient #6's need for colostomy education or supplies in her case management notes. She stated Patient #6 was discharged from the hospital's 5th floor and the "RNs and case managers on that unit are not used to dealing with colostomies." She stated Patient #6 should have received better education and discharge planning. The hospital failed to ensure Patient #6 received the education and discharge planning needed to ensure a safe hospital discharge. 2. Patient #1 was an [AGE] year old female admitted on [DATE], with a diagnosis of sepsis. She was discharged on [DATE]. Her record was reviewed for case management and discharge planning services. Patient #1's record included a "Discharge Summary," dated 5/10/19, signed by a physician. It stated, "She remained slightly hypoxic thought to be due to alveolar hypoventilation and will require low flow O2 [oxygen] post discharge." Patient #1's record included discharge instructions, dated 5/10/19. The instructions stated, "Equipment/supplies: Oxygen therapy." Patient #1's record included a "CASE MANAGEMENT REPORT," dated 5/06/19, signed by a Case Manager. The note stated "Oxygen was ordered but she does not meet criteria." The note did not state how it was determined Patient #1 did not meet criteria for oxygen therapy, as ordered by her physician. It did not state her physician was contacted to clarify her need for oxygen. The Division VP of Nursing Operations was interviewed on 6/12/19 at 5:20 PM. She confirmed Patient #1's discharge summary and discharge orders included oxygen therapy. The Division VP of Nursing Operations confirmed her physician was not consulted to clarify her need for oxygen. Additionally, she confirmed discharge instructions provided to Patient #1 included oxygen, although it was not ordered for her. The hospital failed to ensure Patient #1's discharge instructions were complete and accurate. |
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