HospitalInspections.org

Based on interview and record review, the hospital failed to ensure the Quality Assessment and Improvement Program documented and evaluated actions aimed at improving performance related to the previously identified deficient practices related to wound assessment, patient repositioning, and wound care consultant follow-up. (Refer to A 392. findings 1-5d)

These failures allowed deficient practices to persist that could negatively impact a scope of 71 patients' health status.

Findings:

In an interview on 1/19/16 10:30 am, Administrative Staff A stated the hospital had revised policies and re-educated staff on the policies related to the identification, prevention and treatment of pressure injuries of the skin in response to the deficient practices noted on the last survey.

Review of the nursing care of patients with pressure injuries to their skin revealed a lack of effective and timely nursing assessment and interventions. (Cross reference 392, findings 1, 2, 4, and 5 a-d)

The hospital's Quality/Patient Safety Minutes, dated 9/2016 to 12/2016, included performance measures related to wound photography that indicated no action was needed and the concerns were closed.

The hospital had performance measures related to timely completion of wound care consults and follow up that indicated 100% (percent) performance including for timely consult but varied performance between 22% and 71% for wound care follow-up. There was no evidence in the minutes that indicated actions were evaluated and further actions taken to improve performance. Nursing performance measures for repositioning and wound assessment likewise had varying levels of performance (20-100%) but the minutes did not indicate actions were evaluated and further actions taken aimed at performance improvement when the goal (90%) was not achieved.

The hospital document titled "Quality, Patient Safety, and Performance Improvement Plan FY 2017" indicated the "Quality/Patient Safety Committee has the delegated responsibility for overseeing the hospital-wide performance improvement effort... accomplished through the following activities: 1. Identifying and prioritizing, core organizational process/outcome indicators with appropriate benchmarks, reviewing indicator data to assess performance, determine the effectiveness of improvement/problem-solving activities, and coordinating follow-up and communication to ensure the effectiveness of these efforts."

On 1/19/17 at 3:20 pm, Administrative Staff 7 acknowledged the Quality/Patient Safety Committee minutes did not reflect actions taken and the evaluation of those actions to improve performance of measures related to wound care.

Based on interview and record review, the hospital failed to ensure that the governing body (GB) had reviewed the performance measures related to deficient practices related to the prevention, identification and treatment of wounds. This failure had the potential for deficient practices to persist and negatively impact patients.

Findings:

On 1/19/17 at 2 pm, GB minutes for the months following the last survey (10/2016 to 12/2016) were reviewed. The GB minutes contained no evidence of reports related to nursing and wound care processes since the last survey.

Administrative Staff C was asked to point out any reports related to nursing and wound care studies conducted as a result of the last survey. Administrative Staff C acknowledged that the GB had not been apprised of the quality program or had a chance to evaluate the improvement actions taken.

Based on interview and record review, the hospital failed to ensure that intravenous (IV) saline (salt) solutions used for a malignant hyperthermia emergency was routinely checked to ensure it was stored at an appropriate temperature. Malignant hyperthermia is a rare life threatening condition that occurs when susceptible patients exposed to certain anesthetic agents, and is characterized by a fast rise in body temperature and severe muscle contractions. Immediate response is required for a good patient outcome. This failure had the potential for for a patient to not survive a malignant hyperthermia episode.

Findings:

On 1/18/17 at 10:10 am, the refrigerator, in the anesthesia room, used for storing the IV saline solutions reserved for a malignant hyperthermia emergency was not monitored for temperature every day. The log used for temperature monitoring for this refrigerator contained blanks on 1/2, 1/8, and 1/13/17.

In a concurrent interview, the Director of Perioperative Services acknowledged the refrigerator temperature was not monitored daily to ensure the appropriate temperature of the saline.