HospitalInspections.org

Based upon record review and staff interview it was determined that the hospital failed to provide evidence of reassessment of the patient's nursing care needs, response to nursing interventions and revision to the plan of care for 2 relevant sample patients ID#'s 3 and 14 relative to hand splints.

Findings are as follows:

1. Record review for patient ID#3, who has contractures of both hands, reveals a physician's order dated 10/10/2017 for palm shields with finger separators on in AM after care and off after PM care. The patient's current Care Plan reveals under Goals, hand splint with finger separators on in AM after care and off after PM care.

During surveyor observation on 11/2/2017 at approximately 1:10 PM, the patient did not have on the palm shields. Surveyor observation on 11/3/2017 at approximately 10:10 AM, the patient was again observed without the palm shields with finger separators.

The surveyor interviewed the nursing assistant (NA) assigned to the patient (staff G) who stated she was unaware that the patient had an order for the palm shields with finger separators. She stated that she had received report from the nurse but that there was no mention of the palm shields.

2. Record review for patient ID #14 reveals a physician's order dated 10/13/2017 for resting hand splints from 8:00 PM to 8:00 AM daily. The patient's current Care Plan reveals under Goals, Tolerate RUE (right upper extremity) resting hand splint on with PM care and off with AM care.

Review of the Treatment Sheet revealed the hand splint has not been signed off between October 13 th -October 30 th, 2017.

When interviewed on 10/30/2017 at 2:30 PM, the NA caring for the patient (staff L) revealed the patient did not have the hand splint on when she provided morning care. When the surveyor went to the patient's room with the registered nurse (staff S) to look for the hand splint, it could not be found.

When interviewed on 10/31/2017 at approximately 11:00 AM, the NA caring for the patient (staff M) revealed, the day staff is responsible for removing the splint during morning care. She further revealed that when she performed care on the patient, the patient was not wearing a hand splint.

Another NA who was assisting to care for the patient (staff R) revealed, he did not see the hand splint, and when he went to the room to look for the splint, it could not be found. On 11/1/2017 at 9:00 AM, the NA caring for the patient (staff N) revealed, that the patient was not wearing a hand splint when she provided morning care.

During an interview on 11/1/2017 at 9:30 AM, rehabilitative staff (staff O) revealed, she has asked the patient if the hand splint has been used, the patient replied no that it hadn't. She also revealed there has been an issue with splints being signed off but not being applied.






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Based on record review and staff interview, it has been determined that the hospital failed to have available, radiological services according to the needs of the patients at the Zambarano unit.

Findings are as follows;

Review of the Zambarano unit on call schedule for October 1st -November 4 th, 2017 revealed that staff were available only between 7:30 AM -11:30 AM on Friday 10/13/2017 and 11/3/2017. There was also no staff available on Saturday 10/14/2017 and 11/4/2017 and Sunday 10/15/2017.

During an interview with the chief of Radiology Services on 11/1/2017 at approximately 9:00 AM, she was unable to provide evidence that the radiological services are available on the above dates. She further stated that, occasionally, they have no on-call coverage on weekends and Fridays and that this has been an ongoing issues since July 2017. During telephone interview on 11/10/17 this physician told the surveyor that roughly 10% of patients at the Zambarano Unit have physicians orders and family directives instructing staff not to send patients out for x-rays with the result that patients sometimes wait 2 or 3 days for x-rays.

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Based on surveyor observation and staff interview, it has been determined that the hospital failed to comply with aspects related to the food service operation in accordance with their policy of daily management of dietary services.

Findings are as follows:

The hospital's policy relative to Food Services Equipment/Utensils sates in part:

"...4. Non-food contact surfaces of equipment used in the operation of food service operation, including tables, counters, shelves,... shall be cleaned at such frequency as is necessary to be free of accumulations of dirt, dust and food products..."

1. Surveyor observation of the satellite kitchen in the Adolph Meyer building on 10/31/2017 at 1:10 PM revealed dishes in the two-bay sink in the dishwashing area. When questioned about where to wash their hands, the person in charge (staff P) told the surveyor they could wash their hands in the 2-bay sink. A hand sink in the adjacent area was observed to have items (trays) blocking it.

Surveyor observation of the satellite kitchen in the Adolph Meyer building on 11/1/2017 at approximately 8:30 AM revealed one dietary staff member (staff Q) washing dishes. The staff member was observed to load dirty dishes in the dishwasher and then, without changing gloves or washing hands, hand a cooler and 2 cases of beverages to other staff. Additionally, the hand sink in the area adjacent to the dishwashing area was observed to have trays blocking it.

During a subsequent interview, staff Q acknowledged he had not consistently changed gloves after handling the dirty dishes. When questioned, the staff member stated they usually wash their hands in the 2-bay sink, which he acknowledged is sometimes used to pre-wash dishware.

Subsequent review of the hospital's policy for "Orientation of New Employees" revealed 1.1, In order to optimize the potential for employment success, all newly hired employees will undergo an orientation program. ...1.3 The "Dietary Department Orientation Program" will be used to document the training."

During an interview on 11/2/2017 at 8:55 AM, the Food Service Director acknowledged that dietary staff should change their gloves after handling dirty items. She further stated that they do not maintain records relative to the training that new employees receive for food safety/ kitchen sanitation. Additionally, she stated that staff should not be washing hands in the 2 bay sink where dishware is washed and the hand sink should not be blocked.

2. Surveyor temperature check of the Regan 4 nourishment refrigerator on 10/30/2017 at 3:45 PM revealed the produce temperature was 52 to 54 degrees Fahrenheit (F). The temperature log on the refrigerator stated "refrigerator *temperature should be between 37 (degrees F) and 41 (degrees F). Temperatures not within range are to be reported to the Supervisor Registered Nurse before the end of the shift. Review of the temperature log with the nurse failed to reveal evidence that the temperature had been checked on 10/30/2017.


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3. Surveyor observation of the main kitchen in the Zambarano Unit on 10/30/2017 at 11:08 AM revealed the following:

* In the cooks preparation area, there were 2 long stainless tables approximately 8 feet long. The lower shelf of the tables were noted to have a heavy accumulation of dried food matter/debris.

* The shelves under the two broilers were noted to have a heavy accumulation of dried food matter/debris.

* The shelf under the stand alone grill was noted to have a heavy accumulation of dried food matter/debris.

* The exterior of the convection oven and traditional stovetop/oven were noted to have a heavy accumulation of dried food matter/debris.

On 10/30/2017 at approximately 1:00 PM, in the presence of the Food Service Manager, the above areas were again observed. At this time, she was unable to explain why these surfaces were not clean.

Based on surveyor observation, record review and staff interview, it has been determined that the hospital failed to ensure that the physical condition of the 5th floor in Regan building and the psychiatric units in the Adolph Meyer (AM) building were maintained in a manner to ensure safety and well-being of the patients.

Findings are as follows:

The hospital has been identified as having a litigation risk (i.e. physical structures that could presenta strangulation hazard). Review of the hospital mitigation plan revealed the following :

"...3. Implement the locking of bathrooms; patient's bedrooms to be kept opened while occupied by patients...
5. Implement 5 minutes visual checks of the patients on all psychiatric units to mitigate ligature risk..."

a) Surveyor observation with Supervisor Registered Nurse (staff I) on 10/31/2017 at 1:30 PM revealed several bedroom doors on all units in the AM building were closed but not locked. The surveyor noted that these bedrooms were not occupied by patients. Staff I confirmed to the surveyor that these doors should have been locked.

The 5 minute observation sheets dated 10/31/2017 (3:00 PM-11:11:00 PM shift) lacked evidence that the 5 minutes checks had been completed for 3 of 6 units (AM 7, 10 and 12).

Additional observation of the AM 8 unit with Staff I on 10/31/2017 at 4:00 PM revealed bedroom #3's door was closed but not locked. The surveyor noted that this room was not occupied by patients.

During interview with administrative staff on 10/31/2017 at 4:30 PM, they acknowledged that the 5 minute observation sheets were not completed. They assured the surveyor that the protocol will be followed as indicated in the mitigation plan.

b) Surveyor observation of the psychiatric units on the AM 8 and AM 9 , on 11/2/2017 at approximately 11:30 AM, revealed that ligature risks remained in the rooms, including barrel hinges, grab bars, and grates in the walls.

c) Surveyor observation with the Buildings and Grounds Supervisor of the psychiatric units in the AM building on 11/3/2017 between 8:15 AM and 10:00 AM revealed a total of 75 clothing cabinets on 4 of 6 units (AM 8, 9, 11 and AM 12 units), which were not secured and consequently present a tipping hazard.

d. Surveyor observation of the 5th floor in Regan building on 11/1/2017 at 1:30 PM revealed a free standing stereo cabinet which was not secured and presented a tipping hazard.

During interview on 11/3/2017 at 11:30 AM, the Chief Engineer and Buildings and Grounds Supervisor acknowledged the above cabinets were not secured. He confirmed that cabinets should be secured.

Based on record review and staff interview, it has been determined that the hospital failed to provide evidence that the Infection Prevention and Control Committee include a representative from the Dietary Department. The hospital also failed to ensure that the designated infection control nurse for Zambarano unit meets the qualifications for specialized training in infection control.

Findings are as follows:

a). The Hospital Infection Prevention and Control Plan states in part: "The Infection Prevention and Control Committee is multidisciplinary and involves ..., Dietary,..."

Review of the quarterly Infection Prevention and Control Committee Attendance sheets dated 11/22/2016, 1/31/2017, 4/25/2017 and 8/1/2017 revealed no evidence that the Committee included a representative from the Dietary Department for 3 of 4 meetings.

During an interview on 11/2/2017 at 11:10 AM, the Infection Control Nurse confirmed the above findings.



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b). During surveyor interview on 11/2/2017 at approximately 1:50 PM, the designated infection control nurse at the Zambarano Unit (staff D), acknowledged that she did not have specialized training in infection control, nor had she taken any courses in infection control.

Review of the personal file for staff D on 11/3/2017 at approximately 10:00 AM, lacked any evidence of participation in infection control courses or local or national meetings organized by recognized professional societies or certifications in infection control

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Based on surveyor observation, record review, and staff interviews, it was determined that the hospital failed to monitor compliance with policies, procedures, and protocols for infection control program requirements, and relative to admissions of patients who require isolation, and the appropriate use of personal protective equipment (i.e. gown, gloves, mask) for 3 relevant sample patients (ID's #8, 11, and 12).

Findings are as follows:

a). The hospital's Policy for Infection Prevention and Control Department relative to Placement of a patient on isolation states in part;...

"Level I Contact Precaution... wear gloves when entering the room... Wear a gown when entering the room if you anticipate that your clothing will have substantial contact with the patient, environment surfaces, or items in the patient's room,...

Level II Droplets Precautions: Wear a mask when working within 3 feet of the patient... Wear a gown when entering the room if you anticipate that your clothing will have substantial contact with the patient, environment surfaces, or items in the patient's room,... Wear gloves, ..."

b). The hospital's Policy relative to Medication Tray/Medication Pass Identification, states in part; section h. In the event the patient is on isolation precautions, the nurse will place the photograph in a surgical glove and carry it into the room with the medications without pass tray".

1. Review of the record for patient ID #11 revealed that the patient was readmitted to the facility on 9/27/2017 after a stay at an acute care hospital. The patient has a physician's order dated 9/27/2017 for intravenous antibiotics for 4 days, and an order for level II precautions.

On 11/2/2017 at 9:30 AM, the surveyor observed a nursing assistant (NA), Staff B in ID # 11's room without a gown. During subsequent interview, staff B stated she did not know that the patient was on precautions and therefore was not using a gown while providing direct care.

On 11/2/2017 at 9:40 AM, staff A was observed doning a gown and gloves prior to entering the patient room while carrying the medication tray and the patient's photo, both of which she placed on the bedside table. Upon completion of the medication administration the nurse removed her gown and gloves and returned the medication tray and patient's photo to the medication cart. The surveyor asked the nurse why the patient was on precautions and she revealed she did not know. Additionally, when questioned, she acknowledged that she should not have taken the tray into the patient's room or returned it to the medication cart as the patient was on isolation precautions.

Additionally, during an interview on 11/2/2017 at approximately 11:30 AM, the charge nurse (staff C) stated that she was unaware why the patient is on precautions.

The surveyor interviewed the infection control nurse (staff D) on 11/2/2017 at 1:30 PM, she stated that she was unaware that patient ID #11 was on precautions. She also informed the surveyor that the cultures had not been obtained according to the hospital's policy.

2. On 11/3/2017 at 8:45 AM, the nurse (staff F) was observed by the surveyor taking the blood pressure monitor into patient ID #12's room, who is on Level I Precautions, and taking his/her blood pressure and then returning the blood pressure monitor to the corridor without disinfecting it.

3. On 11/3/2017 at approximately 10:15 AM, the surveyor observed staff H in patient ID # 8's room monitoring him/her on a 1 on 1 observation. The patient was on level II contact precautions, however Staff H was not wearing a gown. When questioned by the surveyor at this time, staff H could not explain why she was not wearing a gown.

The surveyor interviewed the Director of Nurses and the Administrator on 11/3/2017 at approximately 8:05 AM, they were unable to explain staff were not following policies and protocols for infection control.