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Based on review of TQM (Total Quality Management) Meeting Minutes for November 2015 through October 2016, TQM Plan review, and interview, it was determined the facility failed to ensure QAPI (Quality Assurance/Performance Improvement) was reported for discharge planning for the past four quarters (November 2015 to October 2016) as stated in the TQM Plan. The failed practice did not ensure the facility was aware of what improvements needed to be made in discharge planning and had the potential to affect any patient in the facility. Findings follow.

A. Review of TQM Meeting Minutes for November 2015 through October 2016 revealed no QA for discharge planning was reported.
B. Review of the TQM Plan stated, "Regular members shall attend TQM Committee meetings quarterly when their QI (Quality Improvement) report is due."
C. During an interview on 12/13/16 at 1315, the Director of Quality confirmed there was no QAPI for discharge planning.

Based on review of Governing Board Meeting Minutes for November 2015 through October 2016 and interview, it was determined the facility failed to ensure the TQM (total quality management) plan was approved annually by the Governing Board as stated in the TQM Plan. The failed practice did not ensure the Governing Body was responsible for the QAPI program in the facility, and had the potential to affect any patient in the facility. Findings follow.

A. Review of the TQM Plan stated, "The Governing Board, in order to comply with overall responsibility to the TQM program will receive ongoing education and annual review of the TQM Plan."
B. Review of Governing Board Meeting Minutes for November 2015 through October 2016 revealed no evidence of the TQM Plan being approved.
C. In an interview on 12/13/16 at 1315, the Quality Director confirmed the TQM plan had not been approved since October 2015.

Based on policy and procedure review, personnel document review, staffing schedules and interview it was determined the facility failed to follow their policy and procedure in that two of two Registered Nurses did not have Agency Nurse Check off Sheets completed and kept in the Agency Staff Book. Failure to ensure the Agency Nurse Check off Sheet was completed and placed in the designated place did not ensure agency staff were knowledgeable and oriented prior to working their first shift. The failed practice affected all patients who received care from an agency nurse on 10/29/16, 11/03/16, 11/05/16, 11/1916, 11/20/16 and 12/11/16. Findings follow:

A. Review of the policy and procedure titled "Agency Nurses" received from the Director of Nursing (DON) at 1045 on 12/12/16 revealed the following under "Policy: ...#2. There is an Agency Nurse Check off Sheet that will be filled out and kept in front of the nurse's credentials in the Agency Staff Book. This will be filled out by the Assistant DON or DON prior to agency nurse working their first shift and will be signed by them and a second nurse stating that they have both verified the information."

B. Review of Registered Nurse (RN) #1 and #2's personnel documents (nursing license, CPR (cardiopulmonary resusitation) cards, and skin tests) received from the ADON at 1235 on 121416 revealed no Agency Nurse Check off Sheets and none were in the Agency Nurses binder.

C. Review of staffing schedules from 10/29/16 through 11/11/16 revealed RN #1 worked the night shift on 11/03/16, 11/05/16, 11/1916, and 12/11/16 and RN #2 worked the day shift on 10/29/16 and 11/20/16. During an interview with the ADON at 1255 on 12/14/16, she verified the above dates.

Based on clinical record review, policy and procedure review, agency nurse log review and interview it was determined the facility failed to develop a method which established the identity of agency nurses when documenting in the clinical records. Failure to establish a method by which agency nurses identified themselves as the author of nursing notes did not allow the agency nurses names to be reflected in the permanent clinical record. The failed practice affected Swing Bed Patient #2 and Patient #9 on 12/14/16. Findings follow:

A. Review of the electronic portion of the clinical record of Swing Bed Patient #2 revealed on the 12/11/16 nursing note, entries identified as Contract 3 at 2015, 2100, 2138, 2321; on 12/12/16 multiple entries timed 0031, entries timed 0345, 0503, 0504, 0505, 0522 and 0709.

B. During an interview with the Swing Bed Coordinator at 1100 on 12/14/16 she was asked what the Contract 3 meant. The Swing Bed Coordinator stated those were entries by an agency nurse. The Swing Bed Coordinator stated the agency nurses were not set up in the system so they sign in on the PRN (as needed) log at the nurses station as to which PRN badge they have assigned themselves. Review of the PRN log for User ID's (identification) revealed on 12/11/16 on the night shift, Registered Nurse (RN) #1 was assigned to PRN Badge #3.

C. Review of the Swing Bed Policy and Procedure titled "Nursing Documentation" received from the Director of Nursing at 1300 on 12/12/16, revealed under POLICY: ... (at the top of page 2) the following: "Each documented entry shall include the following:
1. Date
2. Time, if appropriate
3. Subject content
4. Signature (first initial and last name) and title (RN, LPN (Licensed Practical Nurse) NA (Nurse Aide) of person making entry."

D. During an interview with the Director of Nursing and the Assistant Director of Nursing at 1110 on 12/14/16, they both verified agency nurses names were not part of the permanent clinical record.

E. Review of the clinical record of Patient #9 revealed on the 12/11/16 nursing note, entries identified as Contract 3 at 1945, 2145, multiple entries timed 2201, 2210, 2334; on 12/12/16 entries at 0025, multiple entries at 0127, 0142, 0330, 0445, 0518, 0530 0618, and 0713.

F. During an interview with the Director of Quality Assurance/Medical Records at 1445 on 12/14/16, she stated there was not a Medical Records policy and procedure that referenced, required or dictated how nursing entries were to be authenticated.

Based on clinical record review, policy and procedure review and interview, it was determined the facility failed to ensure a history and physical for 1 (#2) of 2 (#1 and 2) Swing-Bed patients and 4 (#2, #3, #9 and #10) of 10 (#1-#10) inpatients was not performed with 24 hours as specified by policies. The failed practice did not allow other practitioners to be knowledgeable of the patient's past and current medical and surgical problems. The failed practice created the potential to affect Swing-Bed Patients #1 and #2 and Inpatients #2, #3, #9 and #10. Findings follow:

A. Review of the policy and procedure titled "Physician's Responsibilities" received from the Director of Nursing on 12/12/16 revealed the following under PROCEDURE: ...#7. The history and physical must be pertinent to the Swing-Bed admission.
B. Review of the Medical Staff Rules and Regulations stated, "A complete history and physical will be dictated or written on each hospital admission within 24 hours of admission."
C. Review of the clinical record of Swing-Bed Patient #2 revealed he was admitted to the Swing-Bed program on 12/07/16. Review of the clinical record at 1055 on 12/14/16 revealed it did not contain a history and physical. The above findings were verified in an interview with the Swing-Bed Coordinator #1 at 1055 on 12/14/16.
D. Review of Inpatient clinical records revealed the following:
1) Patient #2 was admitted on 12/11/16. Review of the clinical record on 12/15/16 at 0930 revealed it did not contain a history and physical.
2) Patient #3 was admitted on 12/13/16. Review of the clinical record on 12/15/16 at 0930 revealed it did not contain a history and physical.
3) Patient #9 was admitted on 12/10/16. Review of the clinical record on 12/15/16 at 0915 revealed it did not contain a history and physical.
4) Patient #10 was admitted on 12/12/16. Review of the clinical record on 12/15/16 at 0922 revealed it did not contain a history and physical.
E. The Inpatient and Swing-Bed findings were verified in in an interview with the Swing-Bed Coordinator #1 during the time of record review.

Based on observation, review of Medical Records policy, review of Medical Staff Rules and Regulations and interview, the facility failed to ensure Physician #1 completed 550 clinical records within 30 days as required by Medical Staff Rules and Regulations. By not completing clinical records in 30 days, the facility could not ensure the Patients' clinical records were complete. The failed practice had the likelihood to affect all Patients. Findings follow:

A. During a tour of Medical Records on 12/14/16 at 1430, observation revealed an entire table, with 500+ delinquent clinical records from Physician #1. Some of the records dated back to July 2014. The clinical records had blue tabs indicating missing signatures.
B. Review of Medical Records policy revealed "Medical Records shall be monitored for completion by Medical Records personnel ...Review verbal/telephone orders for authentication by physician within 96 hours".
C. Review of Medical Staff Bylaws stated "If a chart has not been completed within 30 days from date of discharge of the patient, the physician will be notified that he has an additional week to complete the chart before his admission privileges are suspended".
D. During an interview on 12/15/16 at 1251, the Medical Records Director verified the
500+ clinical records, stacked on a table in the Medical Records Department, were delinquent due to Physician #1's missing signatures.

Based on interview, the facility failed to have policies and procedures in place to ensure annual re-certification of Intravenous (IV) Admixture technique for four of four (Pharmacist #1 and #2, Pharmacy Technician #1 and #2) Pharmacy personsonnel trained to compound medications in the Laminar Flow Hood per United States Pharmacopeia Chapter 797, 2008. By not evaluating the competencies of the personnel, the facility could not assure the sterility or accuracy of the medications compounded. The failed practice had the likelihood to affect all patients who received medications compounded in the Laminar Flow Hood. Findings follow:

During an interview with the Director of Pharmacy on 12/13/16 at 1145, the Director of Pharmacy verified they do not have policies and procedures in place to ensure annual re-certification of IV Admixture technique for all personnel trained to compound medications in the Laminar Flow Hood.

Based on observation and interview, it was determined one of one door to the oxygen storage room located in the Respiratory Therapy area was not self-closing. The failed practice had the potential to affect all patients, visitor, and staff in that area because it could not be assured the door would be closed and prevent the spread of smoke and fire during a smoke and fire event in the room. Findings follow:

A. On a tour of the facility on 12/14/2016 at 1010, it was observed the door to the oxygen storage room in the Respiratory Therapy area was not capable of self-closing.
B. During the tour, the Facilities Management Director verified the door to the oxygen storage room was not capable of self-closing.

Referenced code: NFPA 101, 2012 edition; Section 8.4.3.5 See K321.

Based on observation and interview, it was observed in the electrical room located in the surgical corridor, three of four electrical panels did not have a minimum of 36 inches (three feet) of working space in front of the panels because of equipment stored in the electrical room. The failed practice had the potential to affect all patients, visitors, and staff because rapid access to the panels could not be gained in the event of an emergency in addition to creating a potential fire hazard. Findings follow:

A. While touring the facility on 12/14/2016 at 1000, a rack, a cart, and an aspirator were observed stored in front of the electrical panels in the electrical room in the surgical corridor.
B. During the tour, it was verified by the Facilities Management Director the electrical panels were blocked.

Referenced Codes: NFPA 99, 2012 edition, Section: 6.3.2.1; NFPA 70, 2011 edition, Section: 110.26 See K911.

Based on review of the preventative maintenance logs and interview, no evidence was presented to show the facility maintained records for the required monthly testing of two of two Line Isolation Monitors (LIMs) for Operating Room (OR) #1 and #2. The failed practice had the potential to affect all patients and staff in the ORs because it could not be assured that medical equipment used in the ORs would not present an electrical shock hazard. Findings follow:

A. While reviewing the preventative maintenance logs on 12/12/2016 at 1245, no evidence was presented to show the facility performed the required monthly testing on the LIMs for OR #1 and #2.
B. While on tour of the facility on 12/14/2016 at 1000, the Facilities Management Director verified there was no record to show the facility had performed the monthly testing for the LIMs.

Referenced Code: NFPA 99, 2012 edition, Section: 6.3.2.6.3.6 See K914.

Based on observations and interview, it was determined the Infection Control Officer failed to perform surveillance to ensure only currently dated supplies were available for patient use in one (Medical/Surgical Unit, Surgery and Emergency Room) of three (Medical/Surgical Unit, Surgery, and Emergency Room) units. The failed practice had the potential to allow unsterile supplies to be used in patient care. The failed practice had the potential to affect any patient who was assigned to Trauma Room #3. Findings follow:

Observation of the Respiratory Therapy cart in Trauma Room #3 revealed the following: 3/3 Xerofoam gauze patches expired 05/16, 1/1 NP Airway size 8.00 mm (millimeter) expired 07/16, 1/1 Water Seal Chest Drain expired 12/15. The above was verified by the Director of Nursing at 1240 on 12/13/16. In the Lab cabinet a cardiac lab set consisting of 1/1 blue top tube expired 02/16, 1/1 green top tube expired 12/15 and 1/1 purple top tube expired 08/16. The above findings were verified by the Assistant Director of Nursing at 1250 on 12/13/16.


30634

Based on observation and interview, it was determined the Radiology Department and Infection Control Nurse failed to control infections in that was a room labeled "Soiled Utility" was beeing used as a clean utility room. The failed practice created the potential for clean items to become contaminated with soiled items and could affect any patient receiving supplies from that room. Findings follow.

A. During a tour of the Radiology Department on 12/13/16 at 1335, a room marked "Soiled Utility" was observed. Upon entering the room, a toilet was observed at the back of the room; and cabinets full of clean supplies (contrast, linens, gloves, etc) lined one wall.
B. The Radiology Director stated the room was never used to store soiled/dirty supplies, and that the toilet in the room had not been used for as long as she had been there.
C. During an interview at the time of the tour, the Radiology Director confirmed the incorrect labeling of the room.

Based on observation and interview, it was determined the Infection Control Officer failed to identify and control infections in that the Nurse's Station Galley refrigerator/freezer was used for patient food only and not employee food. The failed practice did not ensure patients were receiving only patient foods and not employee foods and had the potential to affect any patient on the unit. Findings follow.

A. During a tour of the Nurse's Station Galley on 12/12/16 at 1250, a refrigerator/freezer was observed. The Dietary Director stated the refrigerator/freezer was designated for patient family members, but was often used for employees. The contents of the refrigerator/freezer revealed the following:
1) Refrigerator-a small, unlabeled, clear plastic container which contained an unidentified beige colored substance; and four of four milk cartons, all of which were opened and unlabeled.
2) Freezer-one of three containers of ice cream, opened and unlabeled, one partially eaten fast food milkshake, and one opened box of pre-portioned raw cookie dough.
B. The area was unlocked and opened so it would be easily accessible to patient's family members.
C. There were no labels designating which foods were for patients/families and which foods were for employees.
D. The Dietary Director stated she did not have a policy related to the Nurse's Station Galley. She confirmed the findings at the time of the tour.


36533

Based on observation, review of Association of PeriOperative Registered Nurses (AORN) Guidelines for Perioperative Practice, Policy and Procedure Manual and interview, it was determined the facility failed to prevent and control infections in that sterilized instruments were stored on an open shelf in the Endoscopy Procedure Room. The failed practice did not assure sterile instruments would remain free from contamination and had the likelihood to affect all patients who received endoscopy services at the facility. Findings follow:

A. Observation on 12/12/16 at 1306 in the Endoscopy Procedure Room revealed seven peel pouches containing sterilized instruments stored in an uncovered plastic bin on the open bottom shelf of the Operating Room Table.
B. Review of the AORN Guidelines for Perioperative Practice, 2015, section XV.b.7 revealed "Sterile items should be stored in closed cabinets or covered carts. Open shelving may be used if it is located in a secure, environmentally controlled, clean area."
C. Review of the Policy and Procedure Manual: Department: Central Service, Page 2 of 2 revealed "Items will be stored in an environment free of moisture, excessive heat or contamination."
D. Findings in A verified during interview with the Infection Control Nurse at the time of observation.

Based on review of manufacturer's instructions for use, review of Cidex ortho-phthalaldehyde (OPA) Solution logs, review of the Policy and Procedure Manual and interview, it was determined the facility failed to prevent and control infections in that the staff did not follow manufacturer's instructions to test the temperature of Cidex OPA Solution in two of two (Endoscopy and Radiology) areas performing high level disinfection of semi- critical equipment. Failure to follow manufacturer's instructions did not assure patients were protected from infection and had the likelihood to affect all patients receiving procedures utilizing semi-critical equipment requiring high level disinfection. Findings follow:
A. Review of Endoscopy Cidex OPA log on 12/13/16 at 0831 revealed no documentation of temperature of Cidex OPA solution for the dates of 01/18/16-12/07/16.
B. Review of Radiology Cidex OPA log on 12/13/16 at 0829 revealed no documentation of temperature of Cidex OPA solution for the dates of 12/20/15-12/12/16.
C. Review of Cidex OPA Solution manufacturer's instructions for use on 12/12/16 at 1404 revealed "High Level Disinfection Manual Processing: High Level Disinfectant at a minimum of 20 degrees Centigrade (68 degrees Fahrenheit)."
D. Review of the Policy and Procedure Manual: SUBJECT: Disinfection in Surgery revealed "Chemical germicides shall be used according to manufacturer's written instructions."
E. Findings in A and B verified during interview with the Infection Control Nurse on 12/13/16 at 0855.

Based on review of manufacturer's instructions for use, review of Cidex OPA Solution logs, review of the Policy and Procedure Manual and interview, it was determined the facility failed to prevent and control infections in that the staff did not follow manufacturer's instructions to test the Cidex OPA Solution for Minimum Effective Concentration (MEC) before each use in two of two (Endoscopy and Radiology) areas performing high level disinfection of semi-critical equipment. Failure to follow manufacturer's instructions did not assure patients were protected from infections and had the likelihood to affect all patients receiving procedures utilizing semi-critical equipment requiring high level disinfection. Findings follow:
A. Review of Endoscopy Cidex OPA log on 12/13/16 at 0831 revealed no documentation of Cidex OPA Solution Test Strips to monitor the concentration of ortho-phthalaldehyde (MEC 0.3%) before each use for the dates of 01/18/16-12/07/16.
B. Review of Radiology Cidex OPA log on 12/13/16 at 0829 revealed no documentation of Cidex OPA Solution Test Strips to monitor the concentration of ortho-phthalaldehyde (MEC 0.3%) before each use for the dates of 12/20/15-12/12/16.
C. Review of Cidex OPA Solution manufacturer's instructions for use on 12/12/16 at 1404 revealed "Use Cidex OPA Solution Test Strips to monitor ortho-phthalaldehyde concentration before each use to detect the MEC (0.3%)."
D. Review of the Policy and Procedure Manual: SUBJECT: Disinfection in Surgery revealed "Chemical germicides shall be used according to manufacturer's written instructions."
E. During interview with the Infection Control Nurse on 12/13/16 at 0845, she confirmed Endoscopy used Cidex OPA Solution for high level disinfection of semi-critical equipment and stated the MEC was checked with Cidex OPA Solution Test Strips one time at the beginning of each day. She stated it was not checked before each use.
F. During interview with the Radiology Director on 12/13/16 at 0855, she confirmed Radiology used Cidex OPA Solution for high level disinfection of semi-critical equipment and stated the MEC was checked with Cidex OPA Solution Test Strips one time at the beginning of each day. She stated it was not checked before each use.

Based on review of manufacturer's instructions for use, review of Cidex OPA Solution logs, review of the Policy and Procedure Manual and interview, it was determined the facility failed to prevent and control infections in that the staff did not follow manufacturer's instructions to not reuse Cidex OPA Solution beyond 14 days in one (Radiology) of two (Endoscopy and Radiology) areas performing high level disinfection of semi-critical equipment. Failure to follow manufacturer's instructions did not assure patients were protected from infection and had the likelihood to affect all patients receiving Radiology procedures utilizing semi-critical equipment requiring high level disinfection. Findings follow:
A. Review of Radiology Cidex OPA log on 12/13/16 at 0829 revealed documentation of Cidex OPA Solution change every 28 days for the dates of 12/20/15-12/12/16.
B. Review of Cidex OPA Solution manufacturer's instructions for use on 12/12/16 at 1404 revealed "Do not reuse beyond 14 days or sooner as indicated by Cidex OPA Solution Test Strips."
C. Review of the Policy and Procedure Manual: SUBJECT: Disinfection in Surgery revealed "Chemical germicides shall be used according to manufacturer's written instructions."
D. During interview with the Radiology Director on 12/13/16 at 0855, she confirmed Radiology used Cidex OPA Solution for high level disinfection of semi-critical equipment and confirmed the solution was changed every 28 days as documented in the Radiology Cidex OPA log.

Based on review of manufacturer's instructions for use and interview, it was determined the facility failed to prevent and control infections in that the facility implemented the use of one of one AgaMatrix Presto blood glucose meter which had no instructions for multi-patient use or disinfection of the meter. Failure to disinfect the blood glucose meter between patients increased the chance of cross contamination. The failed practice had the likelihood to affect all patients requiring blood glucose monitoring. Findings follow:

A. Review of AgaMatrix Presto blood glucose meter directions for use revealed no evidence of documentation as a multi-patient use meter or instructions for disinfection.
B. Review of the Centers for Disease Control and Prevention (CDC) guidelines for infection prevention during blood glucose monitoring and insulin administration revealed "Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared."
C. On 12/14/16 at 0849 a call via speaker phone was placed to AgaMatrix by Infection Control Nurse and Surveyor #1. The AgaMatrix representative stated the AgaMatrix Presto blood glucose meter was not recommended for multi-patient use.
D. Findings in A were verified during interview with the Infection Control Nurse on 12/13/16 at 1408.

Based on interview it was determined the facility failed to develop its scope of surgical services. Failure to develop scope of surgical services did not allow the physicians and surgical services personnel to be knowledgeable regarding what services were approved, appropriate and equipped to be safely performed in the facility. The failed practice affected all patients undergoing surgical procedures in the facility. Findings follow:

A. During an interview with the Surgery Manager at 1322 on 12/13/16, she stated Surgical Services did not have a policy or procedure which addressed the scope of services provided.

Based on interview and review of the surgeon's privileges received from the Operating Room (OR) Nurse Manager at 1320 on 12/13/16, it was determined the facility failed to keep current privileges for three (#1 and #3) of three (#1-3) in the OR and did not have a list of surgeon's whose privileges had been suspended or revoked. Failure to ensure current surgeon's privileges were available to staff and include a list of surgeon' s with revoked or suspended privileges did not allow OR staff to be knowledgeable regarding which surgical procedures the individual surgeons were credentialed to perform as well as those whose privileges were revoked or suspended. The failed practice affected every patient who underwent a surgical procedure in the facility. Findings follow:

A. Review of the surgeon privilege file received from the Surgery Manager at 1320 on 12/13/16 revealed Surgeon #1's privileges dated 2011, Surgeon #2's privileges dated 4/23/15 and Surgeon #3's privileges dated 2011. During an interview with the Surgery Manager at 1320 she verified the above findings.
B. During an interview with the Credentials and ROI (Release of Information) Coordinator at 1430 on 12/13/16 she verified she did not send the Surgery Department copies of current surgical privileges and did not supply them with a list of surgeon ' s whose privileges were revoked or suspended.

Based on review of the Surgical Services Policy and Procedure Manual and interviews, it was determined the facility failed to develop and implement a policy and procedure addressing the Do Not Resuscitate status of operative patients. Failure to develop and implement a policy and procedure addressing the Do Not Resuscitate status of operative patients did not allow the surgeon, the surgical services staff, patients and family members to be knowledgeable, accepting and approving of what steps would be undertaken in the event of the cardiac or respiratory arrest of a patient having surgery. Findings follow:

A. Review of the Surgical Services Policy and Procedure Manual revealed it did not contain policies and procedures addressing the actions the surgeons and surgical staff should take in the event an operative patient experienced a cardiac or respiratory arrest.
B. During an interview with the Surgery Manager at 1325 on 12/13/16 she stated there was not a policy and procedure addressing the Do Not Resuscitate status of operative patients.

Based on personnel record review and interview, it was determined the Facility did not employ a qualified professional to direct the Swing-Bed Activities program and failed to develop and keep current a calendar/schedule of activities for the Swing-Bed patients. Failure to employ a qualified professional did not ensure the Swing-Bed patients were receiving activities designed to meet the interests, physical, mental and psychosocial well-being of each patient. Failure to develop an activities calendar did not allow the swing bed patient and/or family to be knowledgeable of available activities and choose which activities they would like to participate in. The failed practice affected all Swing-Bed patients on 12/13/16. Findings follow:

A. Review of the personnel file of the Activities Director revealed the employee was not a qualified therapeutic recreation specialist, was eligible for certification as a therapeutic recreation specialist or activities professional by or after 10/01/90, was a qualified occupational therapist or completed a State approved training course.
B. The above findings were verified during an interview with the Director of Nursing and the Assistant Director of Nursing at 1555 on 12/13/16.
C. During an interview with Patient #2 at 1350 on 12/13/16 he was asked if he knew what activities were available to him; Patient #2 stated no one had mentioned activities to him.
D. During an interview with the Activities Director at 1430 on 12/13/16 she stated she did not develop a calendar or schedule of activities alerting patients and/or families of what activities are available.