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Based on document review and interview the governing body failed to:

A. insure all departments of the hospital participated in the quarterly Quality Assessment and Process Improvement (QAPI) program of the facility. A review of 4 quarters of QAPI revealed 8 of 23 (Housekeeping, Outpatient/Inpatient Physical Therapy, Trauma, safety Officer, Pharmacy, Lab, Utilization Review/Case Management and Infection Control) departments failed to participate in 1 or more quarterly QAPI meetings.

On 4/16/2014 in the conference room at 10:00 AM in the QAPI program meeting minutes were reviewed and found the following:

Forth Quarter 2012 held February 14 2013
Lab- No report
Infection Control-No report
Housekeeping- No report

First Quarter 2013 held May 9
Housekeeping-Report pending
Outpatient/Inpatient Physical Therapy-Report pending
Trauma-Report pending
Safety Officer-Report pending

Second Quarter 2013 held August 8
Pharmacy- Report pending

Third quarter 2013 held November 14
Lab- No report
Utilization Review/Case Management- No report
Housekeeping-No Report
Safety officer-No report

On 4/17/2014 at 10:00 AM in the conference room an interview with staff #27 confirmed the hospital held quarterly QAPI meetings and all departments were expected to participated in the quarterly QAPI meetings for the facility. Staff #27 confirmed all departments had not participated in the quarterly QAPI meetings. The fourth quarter QAPI meeting for 2013 had not been held as of the date of review.



B. review and approve contracted services for all services provided under contract for 12 months reviewed.

Refer to tag A 0084

C. provide patient rights information for non English proficient patients.

Refer to tag A 0117

Based on document review and interview the facility failed to insure all departments of the hospital participated in the quarterly Quality Assessment and Process Improvement (QAPI) program of the facility. A review of 4 quarters of QAPI revealed 8 of 23 (Housekeeping, Outpatient/Inpatient Physical Therapy, Trauma, safety Officer, Pharmacy, Lab, Utilization Review/Case Management and Infection Control) departments failed to participate in 1 or more quarterly QAPI meetings.

On 4/16/2014 in the conference room at 10:00 AM in the QAPI program meeting minutes were reviewed and found the following:

Forth Quarter 2012 held February 14 2013
Lab- No report
Infection Control-No report
Housekeeping- No report

First Quarter 2013 held May 9
Housekeeping-Report pending
Outpatient/Inpatient Physical Therapy-Report pending
Trauma-Report pending
Safety Officer-Report pending

Second Quarter 2013 held August 8
Pharmacy- Report pending

Third quarter 2013 held November 14
Lab- No report
Utilization Review/Case Management- No report
Housekeeping-No Report
Safety officer-No report

On 4/17/2014 at 10:00 AM in the conference room an interview with staff #27 confirmed the hospital held quarterly QAPI meetings and all departments were expected to participated in the quarterly QAPI meetings for the facility. Staff #27 confirmed all departments had not participated in the quarterly QAPI meetings. The fourth quarter QAPI meeting for 2013 had not been held as of the date of review.

Based on observation, interview and record review the facility failed to:

A. ensure criteria to calculate patient acuity level for nursing staff numbers. The facility failed to ensure telemetry patients were supervised by nursing at all times. The facility failed to ensure sufficient numbers of nursing staff were available at all times on 2 of 2 units (Medical-Surgical unit and Emergency room.)

Refer to A tag 0392 for additional information.

B. ensure ongoing assessments in nutrition, current diet orders and timely pain intervention after complaints of chest pain in 4 or 4 sampled patients (#s' 1, 3, 15 and 16).


Refer to A tag 0395 for additional information.

Based on document review, observation and interview the facility failed to:


A. ensure supplies were protected from being soiled. Three boxes of patient care supplies were found stored directly on the floor in the respiratory therapy supply room. Four isolation supply stations were found with opened boxes of gloves less than two inches from the floor, leading to potential contamination from floor debris. The facility also failed to ensure one medication room sink was maintained in a sanitary condition.

During a tour of the respiratory therapy supply room on 4/15/14 at 1:10pm, three boxes of patient care supplies were found stored directly on the floor. During the tour, staff #2 confirmed this finding.

A tour of the 3rd floor on 4/16/14 at 2:25pm revealed four isolation supply stations with opened boxes of gloves less than two inches from the floor, leading to potential contamination from floor debris. During the tour, staff #7 confirmed this finding.

A tour of the 3rd floor nurses' station medication room on 4/16/14 at 2:30pm revealed a heavily soiled sink, leading to potential cross-contamination. During the tour, staff #7 confirmed this finding.

During an interview on 4/16/14 at 11:55am, staff #7 reported the last time infection control environmental rounds were conducted was in May 2013.




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B. ensure the kitchen maintained a sanitary environment to prevent cross contamination of stored/stocked food supplies and paper products for patient use by removing shipping boxes prior to storage in the immediate kitchen area and shielding these supplies from floor contamination . The facility also failed to maintain equipment in good repair to insure proper sanitizing and failed to prevent grease build-up on flat surfaces which presented the opportunity for cross contamination.

On 4/16/2014 at 9:30 AM a tour of the dietary department revealed the following:

A small storage closet at the back of the kitchen was observed with a large shipping box containing paper products sitting on the floor. Patient use products sitting on the floor pose a risk of cross contamination.

"External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material, serve as generators of and reservoirs for dust." (AAMI ST46-Section 5.2 Receiving items).

The cold storage refrigerator were observed with food stocks stored in their shipping containers, to numerous to count.

A larger closets which contained paper goods, in shipping boxes, was observed with four (4) stainless steel storage racks. Paper products (plates, cups napkins) were stored in shipping boxes on the stainless steel racks. There was no barrier protecting the lower shelf from floor debris posing a cross contamination issue.

A second large closet was observed with four (4) stainless steel storage racks where canned goods were stored. There was no barrier on the lower shelf protecting the canned good from floor debris posing a cross contamination issue.

Two (2) stainless steel preparation (prep) tables were observed with yellow paint on the legs. The paint was chipped and nicked exposing the surface below. Breaks in a painted surface provide a harbor for bacteria and make sanitizing of the surfaces unlikely.

The walk-in freezer motor was observed with a steadily dripping water leak. A large oven roasting pan was observed sitting on frozen food collecting the water as it dripped and refroze. Dripping water posed a avenue for cross contamination of food.

Flat surfaces were found to have a fine greasy film covering them. Debris was observed on coils below the prep tables posing cross contamination issue.

All of the above findings were confirmed by staff #17







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C. ensure furniture and patient use equipment was properly sanitized/disinfected. The facility failed to ensure medications and linen was stored in a manner to prevent cross contamination. The facility failed to ensure medications were dated when opened and ensure expired medications and equipment were discarded.

During an observation of the Medical-Surgical unit on 04/15/2014 after 1:30 p.m., the following was found:
Room #302 and #304 had a chair which had the plastic covering torn and the cushion inside was exposed. There was no way to sanitize the chairs with the torn surfaces.
Room #305, there was approximately 5 cc of solution in an undated syringe which had been left in the patient' s room on the intravenous pump. Staff #5 identified the solution as being normal saline flush.
According to the Association for Professionals in Infection Control and Epidemiology 2012 course book, revealed to "Never set an unlabeled syringe down or leave it unattended."

In the 3rd floor linen room uncovered clean pillows and cushions were stored on the top of the shelf in close proximity to the ceiling. The curtain which was used to cover the clean linen and prevent contaminants was not pulled. There was also a bottle of incontinent/body wash which had been used was stored on the shelf with the clean linen.
In the 3rd floor treatment cart there was two Seasorb soft alginate fillers for wounds expired 08/2013 and one tube of wound dressing Collagen Hydrogel expired 09/2013.
In the 3rd floor medication room there was an open bag filled with smaller plastic bags. The plastic bags were hanging directly underneath the paper towel holder and next to the handwashing sink. The bags were not protected from spills or contaminants. Staff #2 confirmed the bags and identified them as bags used for patients breathing treatment circuits.
The floor underneath the sink in the medication room was bulking. The top coating of the floor stained and peeling back (as from water damage).
In the 3rd floor medication room there were small white cubicles used for storage of patient medications and medication preparation equipment. The cubicles were soiled with yellow and brown spills.
One package of closed hinged wound forceps was in a plastic peel down pack was stored in the medication room. The forceps had been sterilized in a locked position.
According to the www.cdc.gov/hipac/ revealed "Once items are cleaned, dried and inspected, those requiring sterilization must be wrapped or placed in rigid containers should be arranged instrument trays/baskets according to the the guidelines provided by the AAMI and other professional organizations ... These guidelines state that hinged instruments should be opened ...)

Two bottles of glucometer quality control solutions were not dated as to when opened.
During an interview on 04/15/2014 at 3:00 p.m., Staff #5 reported she was not usually cleaning the glucometer between each patient.

According to the manufactures guidelines for the Accu-Check glucometer the " Glucose control solutions are stable for three months after opening or until the expiration date, whichever comes first. The date the vial is opened should be written on the vial label. "
According to the Association for Professionals in Infection Control and Epidemiology 2012 course book, when using point of care testing devices the meter should be " cleaned and disinfected after each use.


In the 3rd floor crash cart a packet of pediatric transparent electrodes expired 11/2013 and a bag of 5 percent Dextrose intravenous fluid which was been removed from the protective covering was found.

According to the Association for Professionals in Infection Control and Epidemiology 2012 course book, intravenous bags should be kept in the plastic overwrap until ready for use. If out overwrap date discard in 30 days.
During interviews on 04/15/2015 Staff #2 and #5 confirmed the observations.


*During an observation of the Emergency room on 04/16/2014 after 12:00 p.m. the following was found:
Waiting area
One chair had the plastic covering torn and the cushion inside was exposed. There was no way to sanitize the chair with the torn surfaces.
Treatment Room A
Five Rapid Rhino nasal packs expired 10/2012;
One Morgan Mediflow lens expired 04/2005;
One Morgan Mediflow lens expired 03/2013;
Two Nasostat expired 04/28/2004;
Ten packets of spinal needles expired 05/2007;
Three packets of spinal needles expired 05/2009;
Two packets of spinal needles expired 06/2008

One bottle of Gentak Ophthalmic solution, Proparacine and Eyewash solution all open and not dated. They were stored in the cabinet with the supplies.
One of the mattresses on a cot had a tear and the inside cushion was exposed. There was no way to sanitize the mattress with the torn surfaces.
One intravenous pump in the room had a tray attached which had a buildup of rust. There was no way to sanitize the pump with the rust buildup.
Treatment Room C
One intravenous pump in the room had a tray attached which had a buildup of rust. There was no way to sanitize the pump with the rust buildup.
The bottom side of the mattress on the cot was soiled with an approximate 12 inch circumference blood stain. The bed frame was also stained with dry blood.
During an interview on 04/16/2014 Staff #19 reported treatment room C had not been used on today. The blood stain was probably from last night.
Main Supply closet
One Gastrostomy feeding tube was expired as of 11/2013.
Treatment Room B
Cetachaine topical anesthetic expired 3/2014;
One 24 French Trochar expired 3/2014;
One box of Ethilon 5-0 sutures expired 01/2013;
One box of Ethilon 4-0 sutures expired 01/2014.
During interviews on 04/16/2014 Staff # 12 and 19 confirmed the observations.

Based on document review and interview the facility failed to review and approve contracted services for all services provided under contract for 12 months reviewed.

On 4/16/2014 at 10:00 AM in the conference room the Governing Body meeting minutes for the previous calendar year were reviewed and found no evidence the contracted services had been reviewed or approved.

On 4/16/2014 in the Administrative offices staff #3 confirmed the contracted services had not been reviewed.

Based on document review and interview the facility failed to provide patient rights information for non English proficient patients.

On 4/15/2014 During a tour of the building, English and Spanish patient rights information was observed. Review of patient admission packets, which contained the detailed patient rights provisions were found only in English. A consent to treat was found in a second language but there was no employee who could read the non English version and explain it.

On 4/16/2014 at 2:00 PM in the Medical Records room staff #16 confirmed the facility did not have patient admission information printed for a second language. The facility had only English proficient information printed for placement in the admissions packet.

Based on observation, interview and record review the facility failed to ensure criteria to calculate patient acuity level for nursing staff numbers. The facility failed to ensure telemetry patients were supervised by nursing at all times. The facility to failed to ensure sufficient numbers of nursing staff were available at all times on 2 of 2 units (Medical-Surgical unit and Emergency room.)



This deficient practice had the likelihood to cause harm to all patients.

Findings include:


During an interview on 04/15/2014 at 1:10 p.m., Staff #5 reported she was the CN and was taking care of 3 patients. There was also 2 other nurses on the unit (1 RN, 1 LVN) and 2 PCAs. Staff #2 reported there was 10 patients on Medical-Surgical unit and 7 were telemetry patients. She reported the nurses on the unit were suppose to be performing monitoring duty also of the telemetry patients.

During an observation on 04/15/2014 at 1:35 p.m. Staff #8 (RN) was pulled to go and assist the emergency room nurse. Staff #5 (CN) reported she took over Staff #8's patients and she would now be caring for 6 patients.

During an observation on 04/15/2014 at 1:40 pm., no one was observed on duty at the nurses station monitoring the telemetry patients.

During an observation on 04/15/2014 at 2:15 p.m., no nurses were at the nurses station. Staff #14 (Respiratory therapy) was at the nurses station and reported he watches the monitors sometimes.

During an interview on 04/15/2014 at 2:15 p.m., Staff #9 (LVN) reported a part of her job duties was to watch the telemetry monitors. Staff #9 reported normally the Supervisor (CN) is up there at the nurses station and she watches them. The nurses normally switched out and took turns watching the patients. Two months ago they had a ward clerk/monitor tech at the nurses station, but they no longer have that position. Staff #9 reported she currently was taking care of 4 patients.

During an observation on 04/15/2014 at 2:35 p.m., no one was at the nurses station watching the monitors.

During an interview on 04/15/2014 at 3:00 p.m., Staff #5 (CN) reported Staff #8 (RN) was still in the emergency room assisting (almost 2 hours later).


Two different staffing grids were provided and made no mention of what criteria to use to determine patient acuity. The following was documented on the staffing grids:


#1
Medical Surgical Higher Acuity Staffing Grid guideline:
Census RN
1-3 1
ER Staffing Guideline
Shift RN/LVN
0700-1900 1 RN
1200-2000 1 RN/LVN (2 nurses)
1900-0700 1 RN*
*Unit Clerk/PCA on duty 1900-0700

#2
Medical/Surgical Staffing Grid
Patient census of 1- 8 called for 1 Supervisor (CN), 1 RN\LVN (2 nurses) on days and evening/night shift.
Patient census of 9 called for 1 Supervisor (CN), 2 RN|LVN (3 nurses) on days and 1RN|LVN on the evening/night shift.
Patient census of 10 -11 called for 1 Supervisor (CN), 2 RN|LVN (3 nurses) on days and evening/night shift.
Patient census of 1-5 called for no PCAs on day and evening/night shift.
Patient census of 6 called for 1 PCA on days and no PCAs on evening/night shift.
Patient census of 7-10 called for 1 PCA on days and evening/night shift.




*Review of staffing records from the time frame of 04/01-15/2014 revealed the following:

04/01/2014, on the evening/night shift there was 1CN and 1 RN and no PCA for a patient census of 10 from 7:00 p.m. -11:00 p.m. The Medical-Sugical unit was short 1 PCA during this time and a nurse.

04/03/2014, on the evening/night shift there was 1 RN, 1 LVN and 1 PCA for 7 patients.
The Emergency room had a total of 14 patients for the day with 1 RN on duty.


04/04/2014, on the day shift there was 1 CN, 1 RN, 1 PCA for 6 patients and the evening/night shift there was 1 RN, 1 LVN and 1 PCA for 7 patients. The Emergency room had a total of 9 patients for the day with 1 RN on duty.

04/05/2014 on the day shift there was 1CN, 1 LVN and 1 PCA for 7 patients. The Emergency room had a total of 13 patients for the day with 1 RN on duty.


04/06/2014 day shift there was 1 CN, 1 LVN, and 1 PCA for 6 patients. On the evening/night shift there was 1 CN, 1RN, and 1 PCA for 6 patients. The Emergency room had a total of 10 patients for the day with 1 RN on duty.


04/07/2014 on the evening/night shift there 1 RN, 1 LVN and 1 PCA for 7 patients.
The Emergency room had a total of 14 patients for the day with 1RN on duty.


4/08/2014 on the evening/night shift there was 1 CN, 1 more RN and 2 PCAs for 10 patients. One of the PCAs was with a patient who was on 1-1 monitoring. The Emergency room had a total of 17 patients for the day with 1 RN on duty.

04/15/2014 on the day shift there was 1 CN, 1 RN, 1 LVN and 2 PCAs for 11 patients.
The Emergency room had seen a total of 10 patients as of 2:35 p.m. with 1 RN on duty. Pulling one nurse from the Medical-Surgical unit left the unit short a nurse.


*On the April 2014 dates mentioned, one nurse being pulled to assist the Emergency room would leave either 1 LVN on the Medical-Surgical unit unsupervised or 1RN on the floor caring for 6 plus patients alone. Neither staffing grids were being followed consistently.

During an interview on 04/15/2014 after 3:40 p.m., Staff #2 confirmed the staffing numbers and that there was no criteria used for assessing acuity. Sometimes the RNs had to leave the Medical-Surgical unit and help the Emergency room nurse with the patient load. Staff #2 reported she was not tracking how often the nurses went to the Emergency room to help. In the event the Emergency room needed assistance on the days she had 1 RN and 1 LVN scheduled on the Medical-Surgical unit, the LVN stayed on the floor and watched the patients. Staff #2 reported she staffed using a ratio of 1 nurse to 6 patients, but there was no policy or staffing plan with this directive.

During an interview on 04/16/2014 at 10:39 a.m., Staff #12 reported the peak hours for the Emergency room was from 12 noon to about 7-8 p.m.
During an interview on 04/16/2015 at 12:00 p.m., Staff #19 reported it was scarey working the Emergency room on the weekends with just 1 nurse.

Review of the policy and procedure named "Nurse Staffing Policy" dated January 2013 revealed the following:
They provided "on premise nursing services 24 hours a day, 7 days a week and with at least 1 Registered Nurse (RN) supervising the service 24 hours a day, 7 days a week.
The Minimum Staffing Guideline Grid (see attached) is utilized and variations shall be made and based on the following:
1. The acuity of the patient-acuity levels will be assessed and based on the needs of the patient. The patient is assessed by the House Supervisor and staffing levels and assignments are adjusted accordingly.
2. The dynamics of the patient's status, including the frequency for specific nursing care activities.
7. Ensuring that staff is available, including a Registered Nurse, to implement emergent resuscitation efforts should the need arise."

Based on interview and record review the facility failed to ensure ongoing assessments in nutrition, current diet orders and timely pain intervention after complaints of chest pain in 4 or 4 sampled patients (#s' 1, 3, 15 and 16).

This deficient practice had the likelihood to cause harm to all patients.

Findings include:


Review of the "ED Rapid Triage" revealed Patient #15 was a 50 year old male admitted on 04/15/2014. At 8:40 p.m. the patient was assessed as having chest pain at an elevated level of 9 ( 0 being the lowest and 10 being the highest), pulse 100 beats/minute and blood pressure of 180/134.
Review of the "ED Physician Notes" were dated 04/15/2014 and timed 8:53 p.m.
Review of "ED medication orders" dated 04/15/2014 revealed the following vasodilators, blood pressure and pain agents:
Nitro SL (sublingual) x 3
Aspirin 325 milligrams by mouth
Clonidine 0.1 milligrams
Toradol 30 milligrams IV (intravenously)
Morphine 2 milligrams IV
The physician orders were signed off by the physician, but were not timed. The medication orders were not complete. There were no parameters written to specify how often, how much to administer and when to hold the medication.
The first documented time that could be found that Patient #15 received something for pain was 9:06 a.m. (26 minutes after presenting to the ED).
Review of a policy named "Pain Assessment and Management" dated 01/2013 revealed the following:
"Unexpected intense pain, particularly if sudden or associated with altered vital signs such as sudden shift in blood pressure, tachycardia or fever, should be immediately evaluated and reported to the physician."
During an interview on 04/16/2014 after 11:00 a.m., Staff #12 confirmed the medication orders.

Review of an "Assessment Report" revealed Patient #1 was a 75 year old female admitted on 04/09/2014 with diagnoses congestive heart failure and chronic obstructive pulmonary disease.
Review of physician orders dated 04/09/2014 revealed an order for the consultant to provide a nutritional assessment.
Review of Patient #1's the record revealed no nutritional assessment had been performed as of 04/17/2014.
During an interview on 04/17/2014 after 9:00 a.m., Staff #2 and #17 confirmed there was no assessment.

Review of an "Assessment Report" revealed Patient #3 was a 72 year old male admitted on 04/12/2014 with diagnoses of pneumonia and uncontrolled diabetes mellitus (blood sugar).
Review of physician orders dated 04/12/2014 revealed Patient #3 was admitted with a diet order for a 2 Gram Sodium, 1800 calorie diet.
Review of the chart revealed no nutritional assessment on Patient #3.
During an interview on 04/17/2014 after 9:00 a.m., Staff #2 confirmed there was no assessment.

Review of an "Assessment Report" revealed Patient #16 was a 93 year old male admitted on 03/29/2014 with diagnoses of urinary tract infection and volume depletion.
Review of the initial nursing dietary "Assessment Report" dated 03/29/2014 revealed Patient #3 had poor dentation, swallowing problems, and unintended weight loss.
Review of physician order revealed Patient #3 had an order for a Diabetic diet written on 03/29/2014, but it was discontinued the same day.
No physician ordered diet could be found nor a dietitian assessment for this patient during his hospital stay.
According to the assessment Patient #3 was discharged on 03/31/2014.

Review of a facility policy named "Nutritional Assessments" and dated 02/2013 the following:
An in-depth nutritional assessment will be performed and documented by the Dietary Manager for each patients identified by the RN ' s Nutritional Screening or other nutritional risk criteria as being at nutritional risk.
2. The following Nutrition Risk Criteria will be used as well as the Dietary Managers judgement:
b. Recent weight loss of greater than 10 % usual body weight.
h. Conditions causing increased needs or decreased intake of nutrient including ... ...
i. Diabetes Mellitus-Type I or II
3. When a nutritional assessment is deemed to be appropriate, Nutritional Assessment will be completed via one chart in patient ' s record.
4. The Nutritional Comments, plan and expected outcomes will be updated following the Protocol for Nutritional Care.

Based on document review and interview the facility failed to insure physician's orders were dated and timed for authentication in 31 of 31 (#1-#31) medical records reviewed.

On 4/17/2014 at 9:00 AM in the Medical Records (MR) department the MR for patient #1-#31 were reviewed and revealed the electronic signature of the physician (MD) reflected no date or time of authentication, thereby rendering the MR unable to authenticate when the MD applied his signature to the order. This was verified by staff #16.