HospitalInspections.org

Based on review of hospital documents, staff interviews and surveyor observations, the hospital's governing body failed to:

a. maintain a complete list of all contracted services provided to the hospital and to evaluate all those services for quality. See tag A-0084 and A-0085;

b. ensure the medical staff conducted periodic appraisals of its members and examined the credentials of candidates for medical staff membership. See Tags A-0338;

c. maintain the hospital to ensure the safety of the patients. See Tag A-0700 and Life Safety Survey Tags K-0067 and K-0147; and

d. maintain an active ongoing infection control program to prevent, control, and investigate infections and communicable diseases to minimize infections and communicable diseases in patients and staff. See Tags A-0747.

These deficient practices had the potential to affect all the patients admitted to the hospital.

Review of the Governing Board Bylaws, documented, "... The Governing Board: a) Provides for compliance with applicable law, regulations, and standards..."

Based on surveyor observations, review of hospital documents and interviews with staff, the hospital failed to implement and maintain an effective and ongoing hospital-wide quality assessment and performance improvement (QAPI) program.

Findings:

1. The hospital failed to ensure infection control activities, issues, and problems, were identified and processed through the QAPI committee with corrective actions and monitoring as needed. See Tag A-0747 and A-0756 for details.

2. The hospital failed to evaluate all contracted services provided to the hospital to ensure quality care was provided. See Tag A-0-84 and A-0085 for details.

Based on document review and staff interview, the hospital failed to ensure:

a. the medical staff conducted periodic conduct appraisals of its members. See Tag A-0340; and

b. credentials of medicals staff members were examined and recommendations made to the governing body. See Tag A-0341.

Based on surveyor observations, review of hospital documents and staff interviews, the hospital was not maintained to ensure the safety of the patients. The hospital failed to:

a. have a preventative maintenance program in place to ensure medical supplies and equipment were maintained and safe for patient use. See Tag A-0724;

b. provide proper heating, ventilation and air conditioning systems throughout the hospital and. See Life Safety Survey Tag K-0067; and

c. maintain the electrical wiring and equipment in accordance with NFPA 70, National Electrical Code 9.1.2. See Life Safety Survey Tag K-0147.

Based on surveyors' observations, staff interviews and review of hospital documents, the hospital failed to maintain an active ongoing program to prevent, control, and investigate infections and communicable diseases to minimize infections and communicable diseases in patients and staff.

Findings:

1. The staff identified as the infection control preventionist did not have ongoing training in establishing and maintaining an effective ongoing infection control program based on current principals and methods of infection control. See Tag A-0748 for details.

2. The hospital failed to ensure the infection control practitioner/nurse developed and maintained an ongoing system for identifying, reporting, analyzing and controlling infections and communicable diseases among patients and staff and ensuring a sanitary environment. See Tag A-0749 for details.

3. During the tour of the hospital on 04/21/2015 between 11:20 a.m. and 1:00 p.m., the surveyors observed a washer and dryer on the patient care area. The washer and dryer were not commercial grade equipment. The hospital failed to ensure infection control policies and procedures were developed and implemented for patient laundry and for cleaning/disinfecting the washer and dryer between patient use. See Tag A-0749 for details.

4. The hospital's leadership failed to ensure infection control activities, issues, and problems, were processed through the quality assessment and performance improvement committee. See Tag A-0756 for details.

Based on document review and staff interview, the governing body failed to ensure all hospital contracted services were subject to quality assessment and performance improvement (QAPI) evaluation.

Findings:

The hospital's contract list was reviewed.

During an interview on 04/22/2015, with staff identified as the Chief Operating Officer and a governing board member, stated the hospital's Committee of the Whole (COTW) was where QAPI is discussed.

Review of the COTW meeting minutes did not contain documentation the contracted services were evaluated.

Based on review of hospital documents and staff interviews, the hospital failed to ensure that there was a complete list of all contracted services provided at the hospital.

Findings:

On the morning of 04/21/2015, surveyors requested a list of all contracted services including contracted individuals and list of services provided.

An undated list was provided to the surveyors to review. The list was not complete. The list did not contain the telemetry, intravenous (IV) pump and preventative maintenance contract providers.

During an interview on 04/22/2015 at 11:00 a.m., staff identified as the Chief Operating Officer and governing board member, stated the contract list provided to the surveyors did not contain the above providers.

Based on document review and staff interviews, the medical staff failed to conduct periodic appraisals for each practitioner appointed to the medical staff. This occurred in five of five (N, O, P, Q, R) credential files reviewed.

Findings:

During an interview on 04/22/2015 at 11:00 a.m., staff identified as the Chief Operating Officer and governing board member, stated she was responsible for the credential files.

Review of credential files N, O, P, Q, R did not contain documentation of appraisals by the medical staff.

Based on review of hospital documents and staff interviews, the hospital did not ensure the medical staff examined the credentials of candidates for medical staff membership. This occurred in five of five (N, O, P, Q, R) credential files reviewed.

Findings:

1. On 04/22/2015 at 11:00 a.m., staff identified as the Chief Operating Officer (COO) and governing board member, stated she was responsible for the credential files. The COO also stated she was aware the credential files were not current.

2. Review of credential files N, O, P, Q, R did not contain documentation of:

~A request for clinical privileges;

~Evidence of current licensure;

~Evidence of training and professional education;

~Documented experience; and

~Supporting references of competence.

Based on medical record review and staff interviews, the hospital did not ensure that all entries in the medical record contain the date and time when they were signed or authenticated in electronic and written form by the person responsible for the services provided. This occurred in fourteen of twenty-seven (#1, 5, 6, 7, 8, 9, 10, 11, 13, 14, 15, 16, 17, 18) medical records reviewed.

Findings:

Medical Record #1 did not contain the date and time the Outpatient Wound Care Note and the History and Physical had been signed by the person responsible for the services provided.

Medical records #5, #7 did not contain the date and time the Progress Notes were signed by the person responsible for the services provided.

The following hospital forms: History and Physical; Discharge Summary and Progress Notes did not contain the date and time they were signed by the person responsible for the services provided in medical records #6, 8, 9, 10, 11, 13, 14, 15, 16, 17, 18.

The hospital forms: Inpatient Wound Care Notes and Wound care Progress Notes did not contain the date and time they were signed by the person responsible for the services provided in medical records #7, 8, 9, 10, 11, 15, 16, 17.

The Case Management assessment in medical record # 14 did not contain the date, time and signature of the person responsible for the services provided.

The Nutrition Evaluation in medical records # 6, 10, 11, 13, 15, 17 did not contain the date and time they were signed by the physician.

The Physical Therapy Evaluation in medical records # 8, 13, 15, 16, 18 did not contain the date and time they were signed by the physician and the physical therapist.

On 04/22/2015 at 11:00 a.m., Staff D stated she was not aware that all entries in the medical records had to be dated and timed.

Based on review of hospital documents and staff interviews, the hospital did not ensure that all physician orders were dated and timed by the ordering practitioner. This occurred in fourteen of twenty-seven (#2, 3, 5, 6, 7, 8, 9, 10, 11, 13, 14, 15, 16, 17) medical records reviewed. In an interview on 04/22/2015 at 11:00 a.m., Staff D stated she was not aware that all entries in the medical records had to be dated and timed.

Based on review of hospital documents and staff interviews, the hospital did not ensure a medical history and physical (h and p) examination was completed and documented for each patient. This occurred in two of two (#5, #7) patients that received hospice care medical records reviewed.

Findings:

Patients #5 was admitted to the hospital on 02/11/2015; Patient #7 was admitted to the hospital on 03/09/2015. Staff D stated both patient were receiving hospice services.

Review of the medical records for #5, #7 did not contain a h and p completed by the physician or other qualified licensed practitioner.

During an interview on 04/22/2015 at 10:30 a.m., Staff D stated h and p's and discharge summaries are not routinely performed on patients that received hospice services.

Based on review of hospital documents and staff interviews, the hospital did not ensure a discharge summary was completed and documented for each patient. This occurred in two of two (#5, #7) patients that received hospice care medical records reviewed.

Findings:

Patient #5 expired at the hospital on 02/14/2015; Patient #7 expired at the hospital on 03/14/2015.

Review of the medical records for Patients #5, #7 did not contain a discharge summary completed by the physician or other qualified licensed practitioner.

On 04/22/2015 at 10:30 a.m., Staff D stated history and physical's and discharge summaries are not routinely performed patients that recieved hospice care.

Based on surveyor observations and staff interviews, the hospital failed to ensure outdated, unusable drugs were not available for patient use.

Findings:

1. A tour of the hospital was conducted on 04/21/2015 between 11:20 a.m. and 1:00 p.m.

2. The following multi-dose medications were observed in the medication room on the nursing unit. The medications were not marked with the date they were opened nor did they have the initials of the person that opened the medication:

~normal saline irrigation solution 250 milliliter (mL)
~ peroxide 16 ounce (oz) bottle;
~ enoxapin sodium injection 300 milligrams(mg)/3 mL and
~Carafate 10 mL.

During an interview on 04/21/2015 at 11:45 a.m., Staff C was asked if the date and initials are required on multi-dose medications, she stated yes.

3. Review of a hospital policy, titled, "Crash Cart Contents and Maintenance", revised July 2014, documented, "...Contents will be maintained and inspected on a regular basis. Any supplies expected to expire within the coming month will be removed and replaced at that time..."

The following expired medications were on the nursing unit crash cart:

~dextrose 5% 1000 mL- expired June 2012
~ 1/2 normal saline 1000 mL- expired June 2012
~dextrose 5% 1/2 normal saline 1000 mL- expired June 2012
~Nitrostat 0.4 mg Tabs- expired January 2015
~Flumazenil 0.1 mg/mL- expired November 2014
~ 2 vials of Lanoxin 0.5 mg/2 mL injection -Expired January 2015
~ sodium bicarbonate 50 mL- Expired December 2014
~ 2 syringes of lidocaine HCL 2% 200 mg/mL - expired February 2015
~2 vials of magnesium sulfate 50% 5 grams(gm)/10 mL -expired February 2015
~ 3 vials of atropine sulfate 0.5% 0.1 mg/mL - expired January 2, 2015
~ 3 vials of epinephrine 1:1000 - expired November 2014

Based on review of hospital documents and staff interviews, the hospital failed to ensure the medical staff periodically reviewed the hospital's formulary system .

Findings:

1. Review of the hospital formulary list provided to the surveyors listed:

~Darvocet N-100 Propoxyphene/APAP 100/650 milligram(mg) oral (PO)
~Darvon Propoxyphene 65 mg PO

2. These two medications were removed from the market in November 2010 by the Federal Drug Administration (FDA).

3. During an interview on 04/21/2015 at 3:00 p.m., Staff D stated the formulary list provided was the current one.

Based on review of hospital documents and staff interviews, the hospital did not have a current therapeutic diet manual that was reviewed and approved by the governing body, dietitian, and medical staff.

Findings:

On 04/21/2015 at 11:00 a.m., the surveyors requested the hospital's therapeutic diet manual.

At that time, Staff J provided the 2009 edition of the Florida Academy of Nutrition and Dietetics and stated that the manual provided was the hospital's current manual.

When asked if this was the most current edition/revision for the approved manual, Staff J stated no.

On 04/21/2015 at 1:00 p.m., Staff J told the surveyors that she had previously ordered the current 2015 edition, but the check had been returned since the company's name had changed. Staff J stated she had not been given another check to order the current edition.

Based on surveyor observations and staff interviews, the hospital failed to have a preventative maintenance program in place to ensure medical supplies and equipment was maintained and safe for patient use.

Findings:

1. A tour of the hospital was conducted on 04/21/2015 between 11:20 a.m. and 1:00 p.m.

2. The inspection and safety check stickers observed on patient care equipment was not current:

~Electrocardiogram inspection due 12/2013
~Pulse Ox machine safety checked 12/18/2012
~"Dinamap" Machine inspection due date 12/2013
~Bladder Scanner inspection due on the sticker 12/2013
~ 2-Portable Manual Blood Pressure Cuff safety checked 12/18/2012
~Lifepak on the crash cart inspection due 06/2014
~"Gomco" suction machine on the crash cart inspection due 12/2013.

The inspection sticker documented the last inspection as 12/2013 on the following physical therapy equipment:

~Cold Machine
~Hydrocollator
~Anodyne (Light Therapy) machine
~2-Ultrasound machines
~Thermaspa

3. On 04/22/2015 at 10:50 a.m., staff identified as the Chief Operating Officer and governing board member, informed the surveyors that the preventative maintenance for the patient care equipment were not current.

4. Review of the Governing Board Bylaws, documented, "...Provides a physical plant, equipment and staff appropriate to the need of the patients and of the community served. The Governing Board will receive periodic reports regarding the aforementioned..."

Based on review of hospital documents, and interviews with hospital staff, the hospital failed to ensure:

a. The staff identified as the infection control preventionist (ICP) had ongoing training in establishing and maintaining an effective ongoing infection control program based on current principals and methods of infection control.

b. The ICP developed and implemented infection control policies and procedures for patient laundry to prevent transmission of communicable diseases.

Findings:

1. On 04/15/2015 at 8:50 a.m., administrative staff identified Staff F as the person responsible for infection control.

Staff F's personnel file documented the individual had been employed as the infection control practitioner/preventionist since 03/17/2014, but did not contain documentation that Staff F had any training in establishing and maintaining an effective and ongoing infection control program.

On 04/21/2015 at 3:00 p.m., Staff F told surveyor she did not have any infection control training in developing and maintaining an effective hospital-wide infection control program.


2. The surveyors requested to review the policies and procedures for the washing and drying of patient items, including the cycles, temperatures and cleaning procedures between patient use.

On 04/21/2015 at 2:45 p.m., Staff Y stated he did not know if the hospital had a policy for patient laundry. None was provided.

On 04/22/2015 at 9:05 a.m., Staff B stated the hospital did not have any policies for patient laundry or for cleaning/disinfecting the washer and dryer between patient use.

Based on surveyors' observations, review of hospital documents, and interviews with hospital staff, the hospital failed to ensure the infection control practitioner/nurse developed and maintained an ongoing system for identifying, reporting, analyzing, controlling and preventing infections and communicable diseases among patients and staff and ensuring a sanitary environment.

Findings:

1. On 04/21/2015, between 11:20 a.m. and 1:00 p.m., the surveyors observed the following:

~Each patient room/suite had two separate bed rooms, with space for two beds in each bed room, and a common area. The bed room on the left side of the common area was designated Beds A and B and the bed room on the right side of the common area was designated Beds C and D.

~ When the surveyors asked why the patients in Room 100, Beds C and D had contact precautions posted on the door, Staff C stated she did not know why. The surveyor reviewed the medical records with Staff C at 11:25 a.m. The records did not contain orders for contact isolation/precautions. Laboratory reports, nursing documentation and physician documentation did not demonstrate either patient had an active infection. Staff E and F, later, told the surveyors that they sometimes put patients with wounds on contact isolation to protect staff and remind them to be careful.

~ Room 103, Beds C and D, had a contact precautions sign posted on the outside door frame. At 11:55 a.m., the surveyor observed Staff S enter the room without any personal protective equipment, including gloves; go to Bed D's bedside and proceed to pull the patient up in bed. Staff S then proceeded to leave the room without performing hand hygiene.

~The door frames for the following rooms had contact precautions signs posted: 100, Bed C and D; 102, Beds C and D; 103, Beds C and D; 104, Beds A and B; 104, Beds C and D; and 105, Beds C and D. At the time of observation on 04/21/2015, the surveyors only saw two isolation carts. The two carts were located in the common area for 100 and 104. Neither cart was stocked with isolation gowns. When this finding was reviewed with Staff F on 04/21/2015 at 3:20 p.m., Staff F told the surveyors that the hospital only had two isolation carts. When asked what the hospital would do when more than two patient rooms needed to be on precautions, Staff F did not answer.

~ Staff C told the surveyor that patients without infections were placed in rooms with patients that did have infections requiring isolation.

~ During the tour of the hospital on 04/21/2015 between 11:20 a.m. and 1:00 p.m., the surveyors observed a washer and dryer on the patient care area. The washer and dryer were not commercial grade equipment. No instructions for use were posted in the laundry rooms. When asked who cleaned/disinfected the washer and dryer between patient use, Staff C stated she did not think they were cleaned between use.

The surveyors requested to review the policies and procedures for the washing and drying of patient items, including the cycles, temperatures and cleaning procedures between patient use.

On 04/21/2015 at 2:45 p.m., Staff Y stated he did not know if the hospital had a policy for patient laundry. None was provided.

On 04/22/2015 at 9:05 a.m., Staff B stated the hospital did not have any policies for patient laundry or for cleaning/disinfecting the washer and dryer between patient use.


2. Infection control policies and procedures and documents supplied to the surveyors did not contain a hospital/community-wide risk assessment or a tuberculosis risk assessment for the hospital. When asked on 04/21/2015 at 3:35 p.m., Staff F stated they had not been done.

3. Although the surveyors asked to review all the infection control surveillance/monitoring for the last 12 months. None was provided. On 04/21/2015 at 3:30, Staff F stated that at the end of each month she looked at all the patients that had been in the hospital during the month and looked to see if they had documentation of an infection. Staff F stated she would report if any of the patient infections were hospital acquired infections.

The surveyor asked Staff F if she monitored hand hygiene, isolation practices or disinfectant application. She said no.

The surveyor asked Staff F if she monitored to ensure the infection control policies in all the different department/areas were performed according to the policies and standards of practice. Staff F said she did not monitor the different departments/areas for compliance with infection control standards of practice.

4. The Committee of the Whole for 10/30/2014, the only meeting minutes containing infection control data, documented Buckeye products as the hospital approved disinfectants/cleaners. During the surveyor observations on 04/21/2015, the surveyors observed PDI Super-Sani Clothes (purple and red top) and Diversity Virex TB in the different areas of the hospital. No Buckeye products were observed.

During the time of the observations on 04/21/2015 between 11:20 a.m. and 1:00 p.m., Hospital Staff C, H, I, and J told the surveyors that these were the products they would use to clean and disinfect the equipment and environment.

On 04/22/2015, Staff B told the surveyors that staff did not like the Buckeye products and so they went back to using the prior disinfectants. Meeting minutes did not document the disinfectants had been reviewed and approved.

This change was not processed through the infection control committee or the Committee of the Whole to ensure the disinfectants were effective against the organisms prevalent in the hospital.

5. Personnel files did not document infection control education/training had been provided to staff since 2013. On 04/21/2015 at 3:20, Staff F stated she had not provided any infection control education to hospital staff.

6. The infection control program did not review employee immunization and illnesses to ensure transmission of infections and diseases did not occur.

The only meeting minute for the past year that contained infection control, 10/30/2014, documented a flu program was in place and vaccination were being given. Fourteen of twenty staff (A, I, K, L, N, O, P, Q, R, S, T, U, V and X) health files requested for review, including employees, contract staff, physician and allied health staff, did not contain documentation of current influenza vaccination.

Eighteen of twenty staff (A, F, G, H, I, K, L, N, O, P, Q, R, S, T, U, V, W and X) health files did not contain documentation of complete immunizations as required.

Based on review of hospital documents and staff interviews, the hospital did not ensure that the Organ Procurement Organization (OPO) was notified of individuals who died in the hospital. This occurred in three of five patients (#5, 7, 27) who died at the hospital.

Findings:

1. The hospital had documented eleven patient deaths from 05/2014 to 04/2015.

2. Review of the medical records and the OPO Referral Sheet for Patients #5, 7, 27 did not contain documentation the patient deaths were reported to the OPO.

3. Patients # 5, #7 were admitted as hospice patients, Patient #27 was admitted as an inpatient; none of the deaths were reported to OPO.

On the afternoon of 04/22/2015, Staff B was asked for the reason the patients were not reported to OPO. Staff B stated Patients # 5, #7 were not reported because they were hospice patients.

Based on review of hospital documents, meeting minutes, and infection control policies and procedures, and interviews with hospital staff, the hospital's leadership failed to ensure infection control activities, issues, and problems, were processed through quality assessment and performance improvement committee (QAPI) and:

a. Were monitored throughout the hospital, reviewed and analyzed;

b. Corrective actions were taken to prevent, identify and manage infections and communicable diseases with measures that resulted in improvement on an ongoing basis; and

c. Corrective actions were followed to ensure improvement resulted and alternative solutions/actions were not needed.

Findings:

1. Upon arrival on 04/21/2015 at 11:00 a.m., the surveyors requested to review the meeting minutes for Governing Body, Medical Staff, QAPI, and Infection Control for the past 12 months. Staff Z told the surveyors the hospital met as a Committee of the Whole. The surveyors were provided meeting minutes for May 30, 2014, June 17, 2014, and October 30, 2014. Staff A told the surveyors on 04/22/2015 that there were no meeting minutes for 2015. The meeting minutes only documented infection control data was presented one time during this period.

2. The meeting minutes did not reflect/contain evidence the hospital leadership:
~ Reviewed and analyzed infection control data or lack thereof;

~ Ensured that all departments/units of the hospital were included and monitored through the infection control/prevention program;

~ Ensured infection control/prevention policies and procedures were developed, implemented and followed to ensure a safe and sanitary environment and that staff were inserviced on those policies;

~ Ensured corrective plans of action were developed to reduce and/or prevent transmission of organisms and improve patient care, ensure a safe and sanitary environment, and prevent or decrease infections and communicable diseases; and

~ Ensured follow-up/monitoring to ensure corrective actions taken were effective and sustainable.


3. Meeting minutes did not contain evidence the hospital's leadership had ensured policies and procedure were developed for all areas of the hospital concerning current accepted standards of practice in infection control. The hospital provided on-site laundry services for patients. No policies had been developed to assure the service was performed according to regulatory requirements and current standards of practice.