HospitalInspections.org

Based on observations, interviews, and documents review, Mesa Hills Specialty Hospital failed to meet the Condition of Participation for Governing Body as evidenced by:


a) The hospital governing body failed to reappointment to the medical staff for 5 of 7 [Staff #B6-7 and #B9-11] physicians or mid-level providers reviewed. In addition, current privileges for these individuals had not been approved by the governing body. Cross refer to A0046.


b) The contracted service that provided dialysis services in the facility did not document pre or post weights on its dialysis patients. While the facility recorded weights most days, they were not put into the patient record - thus were not available to the consulting nephrologists or dialysis nurses. This put the acute dialysis patients at risk for fluid volume overload/deficit. The Governing Body did not ensure that the dialysis contracted service adhered to their own policies and procedures. Cross refer to A0084.


c) Numerous infection control and environment of care issues were noted by surveyors during observations and tours of the facility during the survey. The facility could provide no documented evidence of having addressed these areas of concern in their quality assessment/performance improvement or infection control activities. There was no documented evidence provided to surveyors that data tracked by the facility was interpreted and that subsequent preventive measures were implemented to address identified concerns. Thus, the hospital governing body failed to ensure the facility had an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. Cross refer to A0263.


Facility document entitled "Governing Board By Laws," approved 2/3/09, included the following:

"Section 3 Duties and Responsibilities...

E. Appoint physicians to and remove physicians from the Medical Staff.

F. Grant, modify and terminate clinical privileges of members of the Medical Staff...

K. Review, approve, and periodically reassess and revise a plan for assessing and improving performance; maintaining quality patient care and assuring continuous performance improvement by regularly receiving and acting on, when appropriate, reports, recommendations, and requests for Board action from the Medical Staff, administrative staff and clinical staff on any hospital and Medical Staff operations.

L. Assure that resources are available for maintaining and improving the quality of care provided...

O. Foster a culture that encourages, supports and sustains a continuous performance improvement environment and compliance with all applicable laws, rules, and regulations..."


The cumulative effect of these systemic deficient practices and non-adherence to governing bylaws resulted in hospital non-compliance with the Condition of Participation for Governing Body.

Based on observations, staff interviews, and a review of hospital documentation, Mesa Hills Specialty Hospital failed to meet the Condition of Participation for Quality Assessment and Performance Improvement (QAPI) as evidenced by the hospital failing to:


(1) Analyze quality indicators in order to monitor the effectiveness, safety, and quality of care provided to patients as much of the data collected was either meaningless or not subsequently analyzed or interpreted in order to monitor and improve patient care. (refer to A0273)


(2) Use the data collected to identify opportunities for improvement and changes that would lead to improvement. In addition, the hospital failed to take actions aimed at performance improvement in order to ensure that improvements to patient care and services were implemented, measured and sustained. (refer to A0283)


(3) Conduct performance improvement projects. (refer to A0297)


(4) Ensure the facility's governing board implemented and monitored a hospital-wide, data-driven QAPI program, and failing to maintain and demonstrate evidence of such program. (refer to A0308)

These failed practices resulted in the hospital not assessing or analyzing identified problems, nor addressing opportunities for improvement related to patient care. The cumulative effect of these systemic deficient practices resulted in noncompliance with the Condition of Participation for Quality Assessment and Performance Improvement.

Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Infection Control as evidenced by:


a.) On 8/6/18 two staff members did not remove soiled gloves and wash their hands following Patient #C3's incontinence care, placing patients at risk for infection and cross contamination. One staff lifted a Foley catheter bag over the patient's body, allowing old urine to flow back into the patient, creating an increased risk of infection. (Refer to tag A0756)


b.) A staff member exited Patient #C14's room, known to have C-diff (Clostridium-difficile a spore forming organism), without removing their personal protective equipment and did not wear gloves or wash their hands with soap and water after touching dirty items in the room, placing other patients at risk of cross contamination and infection. (Staff #C5) Patient #C14, currently on Isolation precautions, was left unsupervised in the public hallway. (Refer to tag A0756)


c.) A patient with C-Difficile was placed on an "Enteric Isolation". The facility was not using the required disinfectant for a patient with C-difficile to prevent the possible spread of infection, Staff #C3, CNA, did not know what type of disinfectant was required and the facility did not have a policy for the appropriate disinfectant for Enteric Isolation. (Refer to tag A0756)


d.) The facility's Infection Control Program failed to identify and investigate the cause of hospital acquired infections for two (2) out of five (5) patients. (Refer to tag A0756)


e.) A patient room air conditioner had copious amounts of dirt and blackened dust on the internal vents, placing patients at risk for respiratory infections. (Refer to tag A0756 and tag A0144).


f) The Infection Control Professional of the hospital could provide no documented evidence of training in infection control. (Refer to tag A0748)


g) The facility failed to implement action based on the results of infection control surveillance and identified hospital-acquired patient infections. (Refer to tag A0749)


h) The facility failed to provide access to hospital staff to a current list of state notifiable conditions required to be reported to the state health authority. Thus, staff may not have been aware of communicable disease required to be reported to state authorities. (Refer to tag A0750)


i) The facility failed to ensure maintenance of a sanitary hospital environment. (Refer to tag A0751)

The cumulative effect of these systemic deficient practices resulted in noncompliance with the Condition of Participation for Infection Control.

Based on a review of facility documentation and staff interview, the hospital governing body failed to document reappointment to the medical staff for 5 of 7 [Staff #B6 - 7 and #B9 - 11] physicians or mid-level providers. In addition, current privileges for these individuals had not been signed as approved by the governing body upon reappointment.


Findings were:


A review of the "Mesa Hills Specialty Hospital Hospital [sic] Medical Staff Bylaws" revealed the following:

"Article 4

Procedures for Appointment and Reappointment

4.1 General ...

The Governing Board shall ultimately be responsible for granting membership and Privileges (provided, however, that these functions may be delegated to the Chief of Staff and Chief Executive Officer with respect to requests for temporary Privileges) ...

Reappointment and Privileges ...

Governing Board ...Review recommendations of the Medical Executive Committee; make decision ...Final Action ...

4.5 Approval Process for Appointments and Reappointments

4.5-1 Recommendations and Approvals ...

The Medical Executive Committee shall make a recommendation to the Governing Board that is either favorable, adverse or defers the recommendation ...

4.5-2 The Governing Board's Action

The Governing Board shall review any favorable recommendation from the Medical Executive Committee and take action by adopting, rejecting, modifying or sending the recommendation back for further consideration...

b. The Governing Board shall make its final determination giving great weight to the actions and recommendations of the Medical Executive Committee. Further, the Governing Board determination shall not be arbitrary or capricious, and shall be in keeping with its legal responsibilities to act to protect the quality of the medical care provided and the competency of the Medical Staff, and to ensure the responsible governance of the Hospital ..."


A review of the credentialing files of hospital physicians and mid-level providers revealed 5 of 7 [Staff #B6 - 7 and #B9 - 11] included no evidence of current medical staff appointment or reappointment from the Governing Board. The only evidence of reappointment included in the files was a list of privileges requested by the provider that had not been approved by the Governing Board.


In an interview with Staff #B3, Administrative Assistant responsible for medical staff appointments and reappointments, on the afternoon of 8/7/18 at 2:15 p.m., she confirmed that the hospital Governing Board had not approved the privileges requested by the above physicians and mid-level providers upon reappointment, and that the files did not include a letter from the Governing Board confirming their reappointments.

Based on review of documentation and interview, it was determined that the governing body did not ensure that contracted service providers delivered patient care in a safe and effective manner.

Findings were:

In an article entitled "Body Water-Body Weight" by John De Palma MD, FACP and Joanne Pittard MS, RN dated 2001 and found @ http://www.hemodialysis-inc.com/articles/bodywater.pdf stated in part "Proper control of body weight - body water, like dialysis dose, is one of the important issues and risk factors that contribute to the morbidity and mortality of ESRD patients. Without knowledge of body weight - body water, the health-care giver cannot render adequate dialysis care. In a hemodialysis facility, the classic four vital signs of: temperature, pulse, respirations, and blood pressure should be supplemented with the patient's actual weight both pre and post dialysis."


US Renal Care policy entitled "Hemo Standing and PRN Orders" stated in part "Weight: record pre and post treatment weights."


US Renal Care policy entitled "Pre Dialysis Patient Assessment" stated in part "Obtain pre-dialysis weight. Compare with target weight (if available) and previous post-dialysis weights to determine the amount of fluid to be removed, if not specified from the nephrologist."


US Renal Care policy entitled "Patient Assessment Post Treatment" stated in part "Report to hospital staff nurse any pertinent events occurring during the dialysis, vital signs and weight post dialysis, fluids and medications given, volume removed and the patient's condition.


The following acute dialysis patients' medical records were reviewed:


Patient #1Roster B (admitted 7/31/18) revealed no pre or post dialysis weights documented for the following days: 7/31/18, 8/1/18, 8/2/18, 8/3/18, and 8/4/18.


Patient # 3 Roster B (admitted 6/5/18) revealed no pre dialysis weights documented for the following days: 6/7/18, 6/8/18, 6/9/18, 6/11/18, 6/13/18, and 6/15/18.


Patient # 5 Roster B (admitted 7/18/18) revealed no pre or post dialysis weights documented for the following days: 7/21/18, 7/23/18, 7/24/18, 7/25/18, 7/26/18, 7/28/18, and 7/30/18.


In an interview with the Director of Nurses on 8/7/18, it was confirmed that the contracted service that provided dialysis services in the facility did not document pre or post weights on its dialysis patients. While the facility recorded weights most days, they were not put into the patient record-thus were not available to the consulting nephrologists or dialysis nurses.

Based on review of documentation and interview, it was determined that the facility failed to include the patient or his/her representative in the Care Plan process.


Findings were:


Facility policy entitled "Care Planning" stated in part, "The team should use the problem list to create an individualized, comprehensive treatment plan, which reflects immediate short and long term goals and barriers/contingencies. Timelines and the what, where and how, to include the frequency and interventions, will be implemented to meet the important aspects of the treatment plan. The care must have the approval of all parties including the family who may sign the care plan as an acceptance if they wish. Care plans should be reviewed daily by the nurses caring for the patient."


In an interview with Staff Member # 4 (RN) Roster B, she stated, "We have care plan meetings every Tuesday. Families and patients do not participate in weekly care plan meetings."


Review of 10 of 10 current patient medical records revealed no documented evidence of patient or family participation in the care plan process.


In an interview with the CEO on 8/7/18, the lack of patient and family involvement in the care plan process was confirmed.

Based on a review of facility documentation, staff interviews, and observations, the facility failed to ensure a safe setting for all patients as hospital staff failed to evaluate identified patient and environmental problems, and implement corrective action to correct these problems.


Findings were:


A review of the hospital document entitled "Patients Rights and Responsibilities," no effective date, included the following:

" ...The right to an environment that supports safety from environmental hazards ..."


Facility policy entitled "Safety Management Plan," last revised 2/2016, included the following:

"The hospital will be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. The condition of the physical plant and the overall hospital environment will be developed and maintained in such a manner that the safety and well-being of the patients are assured ...

The hospital will establish and maintain a safe, functional environment ...

Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment, and services provided ...Including storage space to meet patient needs ...
Keeps furnishings and equipment safe and in good repair ..."


A tour of Mesa Hills Specialty Hospital on the morning of 8/7/18 with Staff #B5, Director of Maintenance, and Staff #B1, Director of Nursing, revealed the following infection control issues:


· Ill-fitting and openings in ceiling tiles throughout the facility, including in patient supply central storage areas and patient care areas. Openings in ceiling tiles allow a portal into the area below for dust, debris and pests to enter which can contaminate items below.
·
· Large and small areas of broken laminate were found throughout the facility on furniture in patient rooms, around sinks, and in patient supply areas. Broken laminate exposes the permeable surface underneath and makes thorough cleaning impossible.
·
· The refrigerator in the patient nourishment area had a temperature log which consistently noted the temperature above the acceptable range in May and June 2018. There were additional such listings in July. No action was documented resulting from the out-of-range temperatures in May and June. There was no evidence that maintenance was notified, or that food items were removed. In addition, there was a thick layer of ice in the freezer which also poses an infection control risk. The refrigerator contained hospital-provided patient snacks and family food items.
·
· The ice machine had dark mold deposits on the clear plastic dispenser area. Water was dripping from the dispenser and the machine generally appeared to need cleaning.
·
· In the respiratory ABG (arterial blood gas) lab, there was again broken laminate on the cabinets, making thorough cleaning impossible. In addition, an air conditioning unit against the wall was dirty and had a broken plastic covering.
·
· Cracked floor tiles were found throughout the facility. These make thorough cleaning of the floor impossible.
·
· In room 501, an opening in the ceiling around the sprinkler head allowed for the entry of dirt, dust, and pests. The ceiling appeared to be fairly new, but the opening had been left at the time of repair.
·
· In room 512, the room had been cleaned and was ready for patient use. The patient table still had a stain about an inch in diameter which appeared possibly to have been old coffee.
·
· In room 502, there was an anteroom area with a sink and cabinets. When two of the cabinets were inspected, the bottoms contained large areas of dirt and old stains.


The above findings were confirmed with Staff #B1 and Staff #B5 during the facility tour.








33326


Based on observation, interview and record review, the facility failed to follow-up on an incident report and provide a corrective action when a broken air conditioner that had sparked and had the potential to cause a fire was left in service.


Findings Include:


Review of an incident report dated 8/8/18 reflected, "... went into room to turn off air conditioner because it was making to [sic] much noise. We turned it off a couple of times, but when we would go into the room the air conditioner was on again, by around 05:00 my coworkers and I had to unplug it so it would go off. When I unplug [sic] it, it sparked ...."


An observation on the morning of 8/8/18, in the facility patient room #503, revealed the patient had been moved out of the room and the air conditioner was plugged in and was on. There was a slight burnt mechanical odor in the room. There was no signage to indicate the air conditioner was out of order and the room was not blocked from being used.


During an interview on the morning of 8/8/18, in the staff lounge, Staff #C10, Safety Officer stated, "I plugged it in... I hadn't fixed it yet.... I think it's the fan blade hitting on the housing ...." When asked if he had informed the nursing staff that the air conditioner was out of service or had prevented staff from using the unit, Staff #C10 stated, "No."


The State Life Safety Inspector was present during the interview of the Safety Officer. When the Inspector was asked if the blade hitting the housing could cause a fire the Inspector stated, "It could."


On the morning of 8/8/18 Staff #C10, Safety Officer confirmed the finding.

Based on a review of facility documentation and staff interview, the facility failed to ensure the QAPI program focused on indicators related to improved health outcomes and the prevention and reduction of medical errors, the facility could provide evidence that the data collected and reported by the facility director of quality was analyzed, interpreted or used to improve patient health outcomes.


Findings were:


A review of the the "Mesa Hills Specialty Hospital 2018 Performance Improvement Plan," no effective date, revealed the following:

"Performance Improvement ...

The Healthcare staff leadership is committed to providing an environment which encourages performance assessment and improvement of patient care and services, as well as governance, managerial, clinical and support functions.

To fulfill these obligations, Mesa Hills Specialty Hospital Governing Board, Medical Staff, Leadership and employees have established a performance improvement program consistent with the mission, vision, values and strategic plan. The systems and processes for improvement are prioritized by the hospital's leadership so that appropriate planning takes place and resources are allocated ...

Objectives ...

o To promote the use of benchmarks and reference databases for comparison

o To demonstrate improvement both systematically and collaboratively in processes which have been established as priorities ...


Authority and Accountability

The Governing Board has the ultimate authority and responsibility for performance improvement...


Oversight ...

The QAPI's responsibilities include, but are not limited to: ...

o Prioritizing performance improvement projects

o Reviewing and approving performance improvement team projects ...

o Evaluating the effectiveness of action taken to improve a process ...


Program Approach ...

o Measurement is the systematic collection of data to

o Evaluate the design of new procedures and processes

o Evaluate the stability of important existing functions, processes and outcomes

o Identify both processes and outcomes for improvement

o Effectively evaluate actions taken to impact the anticipated outcome


The collected data will be assessed systematically using ...

o Benchmarks, reference data bases, accreditation/licensure standards and practice guidelines ..."


This plan was the only QAPI program provided for surveyor review. The plan was not signed as approved, though there was a signature line provided for a representative of the governing board to indicate plan approval.


A review of the QAPI committee meeting minutes for 2018 revealed meetings were held on the following dates: 1/25/18, 2/26/18, 3/26/18, and 4/23/18. No additional meetings had been held since April 2018. The minutes appeared to include data collected by the director of quality, but there was no evidence of that data having been interpreted or implemented to improve patient care outcomes. There was no evidence that the information had been assessed according to benchmarks or reference data bases. In addition, there was no evidence of the governing body having identified quality indicators relevant to patient care for the hospital.


In an interview with Staff #B1, the Director of Nursing, on the afternoon of 8/6/18 at 1:25 p.m. in the facility conference room, she stated, "The 2018 Performance Improvement Plan is just a draft. That hasn't been approved yet, and it's just what we've started with." When asked if the plan had been created as a result of the recent accrediting organization survey, she stated, "That is correct. There was no real quality program prior to that survey date, though some issues were being addressed. But there was no effective program in place. I haven't been here that long ...It was identified that we're not interpreting what the numbers mean that we've been collecting ..." She confirmed that quality indicators followed by individual departments had not been determined as part of a hospital-wide integrated quality program.


A review of the minutes of meetings of the facility's Medical Executive Committee for 2018 revealed, the only indicators included with the minutes as reviewed by the committee were for the Admissions Office. The percentages were for # of patients admitted by referral from a particular area hospital divided by the number of patients referred by that same hospital. For example, a specific hospital might have referred 6 patients to Mesa Hills Specialty Hospital and of those, 3 were admitted. This was given as an indicator result of 50%.


During the above-mentioned interview with the Director of Nursing on the afternoon of 8/6/18, she agreed that the data collected and percentages were essentially meaningless.

Based on a review of facility documentation and staff interview, the facility failed to take actions aimed at performance improvement, and after implementing those actions, measured its success and tracked performance related to improved health outcomes and the prevention and reduction of medical errors.


Findings were:


A review of the the "Mesa Hills Specialty Hospital 2018 Performance Improvement Plan," no effective date, revealed the following:

"Performance Improvement ...

The Healthcare staff leadership is committed to providing an environment which encourages performance assessment and improvement of patient care and services, as well as governance, managerial, clinical and support functions.


To fulfill these obligations, Mesa Hills Specialty Hospital Governing Board, Medical Staff, Leadership and employees have established a performance improvement program consistent with the mission, vision, values and strategic plan. The systems and processes for improvement are prioritized by the hospital's leadership so that appropriate planning takes place and resources are allocated ...


Objectives ...

o To promote the use of benchmarks and reference databases for comparison

o To demonstrate improvement both systematically and collaboratively in processes which have been established as priorities ...


Authority and Accountability

The Governing Board has the ultimate authority and responsibility for performance improvement...


Oversight ...

The QAPI's responsibilities include, but are not limited to: ...

o Prioritizing performance improvement projects

o Reviewing and approving performance improvement team projects ...

o Evaluating the effectiveness of action taken to improve a process ...


Program Approach ...

o Measurement is the systematic collection of data to

o Evaluate the design of new procedures and processes

o Evaluate the stability of important existing functions, processes and outcomes

o Identify both processes and outcomes for improvement

o Effectively evaluate actions taken to impact the anticipated outcome


The collected data will be assessed systematically using ...

o Benchmarks, reference data bases, accreditation/licensure standards and practice guidelines ..."


This plan was the only QAPI program provided for surveyor review. The plan was not signed as approved, though there was a signature line provided for a representative of the governing board to indicate plan approval.


A review of the QAPI committee meeting minutes for 2018 revealed meetings were held on the following dates: 1/25/18, 2/26/18, 3/26/18, and 4/23/18. No additional meetings had been held since April 2018. The minutes appeared to include data collected by the director of quality, but there was no evidence of that data having been interpreted or implemented to improve patient care outcomes. There was no evidence that the information had been assessed according to benchmarks or reference data bases. In addition, there was no evidence of the governing body having identified quality indicators relevant to patient care for the hospital.


In an interview with Staff #B1, the Director of Nursing, on the afternoon of 8/6/18 at 1:25 p.m. in the facility conference room, she stated, "The 2018 Performance Improvement Plan is just a draft. That hasn't been approved yet, and it's just what we've started with." When asked if the plan had been created as a result of the recent accrediting organization survey, she stated, "That is correct. There was no real quality program prior to that survey date, though some issues were being addressed. But there was no effective program in place. I haven't been here that long ...It was identified that we're not interpreting what the numbers mean that we've been collecting ..." She confirmed that quality indicators followed by individual departments had not been determined as part of a hospital-wide integrated quality program.


A review of the minutes of meetings of the facility's Medical Executive Committee for 2018 revealed the only indicators included with the minutes as reviewed by the committee were for the Admissions Office. The percentages were for # of patients admitted by referral from a particular area hospital divided by the number of patients referred by that same hospital. For example, a specific hospital might have referred 6 patients to Mesa Hills Specialty Hospital and of those, 3 were admitted. This was given as an indicator result of 50%.


During the above-mentioned interview with the Director of Nursing on the afternoon of 8/6/18, she agreed that the data collected and percentages were essentially meaningless.

Based on a review of facility documentation and staff interview, the facility failed to conduct performance improvement projects.


Findings were:


A review of facility documentation related to quality assessment and performance improvement revealed no documented evidence of any hospital-wide performance improvement project.

In an interview with the Staff #B17, the hospital CEO, and Staff #B1, Director of Nursing, on the afternoon of 8/6/18 at 1:25 p.m. in the facility conference room, they were asked if the hospital was conducting performance improvement projects. They both stated it was not.

Based on a review of facility documentation and staff interview, the facility governing body failed to ensure that the hospital QAPI program reflected the complexity of the hospital's organization and services as the hospital failed to maintain and demonstrate evidence of having a functional and meaningful QAPI program.


Findings were:


A review of the the "Mesa Hills Specialty Hospital 2018 Performance Improvement Plan," no effective date, revealed the following:

"Performance Improvement ...

The Healthcare staff leadership is committed to providing an environment which encourages performance assessment and improvement of patient care and services, as well as governance, managerial, clinical and support functions.


To fulfill these obligations, Mesa Hills Specialty Hospital Governing Board, Medical Staff, Leadership and employees have established a performance improvement program consistent with the mission, vision, values and strategic plan. The systems and processes for improvement are prioritized by the hospital's leadership so that appropriate planning takes place and resources are allocated ...


Objectives ...

o To promote the use of benchmarks and reference databases for comparison

o To demonstrate improvement both systematically and collaboratively in processes which have been established as priorities ...


Authority and Accountability

The Governing Board has the ultimate authority and responsibility for performance improvement...


Oversight ...

The QAPI's responsibilities include, but are not limited to: ...

o Prioritizing performance improvement projects

o Reviewing and approving performance improvement team projects ...

o Evaluating the effectiveness of action taken to improve a process ...


Program Approach ...

o Measurement is the systematic collection of data to

o Evaluate the design of new procedures and processes

o Evaluate the stability of important existing functions, processes and outcomes

o Identify both processes and outcomes for improvement

o Effectively evaluate actions taken to impact the anticipated outcome


The collected data will be assessed systematically using ...

o Benchmarks, reference data bases, accreditation/licensure standards and practice guidelines ..."


This plan was the only QAPI program provided for surveyor review. The plan was not signed as approved, though there was a signature line provided for a representative of the governing board to indicate plan approval.


A review of the QAPI committee meeting minutes for 2018 revealed meetings were held on the following dates: 1/25/18, 2/26/18, 3/26/18, and 4/23/18. No additional meetings had been held since April 2018. The minutes appeared to include data collected by the director of quality, but there was no evidence of that data having been interpreted or implemented to improve patient care outcomes. There was no evidence that the information had been assessed according to benchmarks or reference data bases. In addition, there was no evidence of the governing body having identified quality indicators relevant to patient care for the hospital.


In an interview with Staff #B1, the Director of Nursing, on the afternoon of 8/6/18 at 1:25 p.m. in the facility conference room, she stated, "The 2018 Performance Improvement Plan is just a draft. That hasn't been approved yet, and it's just what we've started with." When asked if the plan had been created as a result of the recent accrediting organization survey, she stated, "That is correct. There was no real quality program prior to that survey date, though some issues were being addressed. But there was no effective program in place. I haven't been here that long ...It was identified that we're not interpreting what the numbers mean that we've been collecting ..." She confirmed that quality indicators followed by individual departments had not been determined as part of a hospital-wide integrated quality program.


A review of the minutes of meetings of the facility's Medical Executive Committee for 2018 revealed the only indicators included with the minutes as reviewed by the committee were for the Admissions Office. The percentages were for number of patients admitted by referral from a particular area hospital divided by the number of patients referred by that same hospital. For example, a specific hospital might have referred 6 patients to Mesa Hills Specialty Hospital and of those, 3 were admitted. This was given as an indicator result of 50%.


During the above-mentioned interview with the Director of Nursing on the afternoon of 8/6/18, she agreed that the data collected and percentages were essentially meaningless.

Based on a review of facility documentation and staff interview, the facility governing body failed to ensure that the hospital QAPI program reflected the complexity of the hospital's organization and services as the hospital failed to maintain and demonstrate evidence of having a functional and meaningful QAPI program. Nor was the facility able to provide documented evidence of any hospital-wide, data-driven performance improvement projects.


Findings were:


A review of the the "Mesa Hills Specialty Hospital 2018 Performance Improvement Plan," no effective date, revealed the following:

"Performance Improvement ...

The Healthcare staff leadership is committed to providing an environment which encourages performance assessment and improvement of patient care and services, as well as governance, managerial, clinical and support functions.

To fulfill these obligations, Mesa Hills Specialty Hospital Governing Board, Medical Staff, Leadership and employees have established a performance improvement program consistent with the mission, vision, values and strategic plan. The systems and processes for improvement are prioritized by the hospital's leadership so that appropriate planning takes place and resources are allocated ...


Objectives ...

o To promote the use of benchmarks and reference databases for comparison

o To demonstrate improvement both systematically and collaboratively in processes which have been established as priorities ...


Authority and Accountability

The Governing Board has the ultimate authority and responsibility for performance improvement...


Oversight ...

The QAPI's responsibilities include, but are not limited to: ...

o Prioritizing performance improvement projects

o Reviewing and approving performance improvement team projects ...

o Evaluating the effectiveness of action taken to improve a process ...


Program Approach ...

o Measurement is the systematic collection of data to

o Evaluate the design of new procedures and processes

o Evaluate the stability of important existing functions, processes and outcomes

o Identify both processes and outcomes for improvement

o Effectively evaluate actions taken to impact the anticipated outcome


The collected data will be assessed systematically using ...

o Benchmarks, reference data bases, accreditation/licensure standards and practice guidelines ..."


This plan was the only QAPI program provided for surveyor review. The plan was not signed as approved, though there was a signature line provided for a representative of the governing board to indicate plan approval.

A review of the QAPI committee meeting minutes for 2018 revealed meetings were held on the following dates: 1/25/18, 2/26/18, 3/26/18, and 4/23/18. No additional meetings had been held since April 2018. The minutes appeared to include data collected by the director of quality, but there was no evidence of that data having been interpreted or implemented to improve patient care outcomes. There was no evidence that the information had been assessed according to benchmarks or reference data bases. In addition, there was no evidence of the governing body having identified quality indicators relevant to patient care for the hospital.


In an interview with Staff #1, the Director of Nursing, on the afternoon of 8/6/18 at 1:25 p.m. in the facility conference room, she stated, "The 2018 Performance Improvement Plan is just a draft. That hasn't been approved yet, and it's just what we've started with." When asked if the plan had been created as a result of the recent accrediting organization survey, she stated, "That is correct. There was no real quality program prior to that survey date, though some issues were being addressed. But there was no effective program in place. I haven't been here that long ...It was identified that we're not interpreting what the numbers mean that we've been collecting ..." She confirmed that quality indicators followed by individual departments had not been determined as part of a hospital-wide integrated quality program.


A review of the minutes of meetings of the facility's Medical Executive Committee for 2018 revealed the only indicators included with the minutes as reviewed by the committee were for the Admissions Office. The percentages were for # of patients admitted by referral from a particular area hospital divided by the number of patients referred by that same hospital. For example, a specific hospital might have referred 6 patients to Mesa Hills Specialty Hospital and of those, 3 were admitted. This was given as an indicator result of 50%.


During the above-mentioned interview with the Director of Nursing on the afternoon of 8/6/18, she agreed that the data collected and percentages were essentially meaningless.


In addition, a review of facility documentation related to quality assessment and performance improvement revealed no documented evidence of any hospital-wide performance improvement project.


In an interview with the Staff #17, the hospital CEO, and Staff #1, Director of Nursing, on the afternoon of 8/6/18 at 1:25 p.m. in the facility conference room, they were asked if the hospital was conducting performance improvement projects. They both stated it was not.

Based on interview and record review, the facility failed to provide appropriate incontinence care and inserted a Foley catheter on patients without a physician's order. (Patients #C2 and C3)


Findings include:


Observations made on the afternoon of 8/6/18 at 2:20 pm, on the inpatient unit, revealed Patient #3 receiving incontinence care. Staff #C2, Certified Nursing Assistant (CNA) and Staff #C3, RN (Registered Nurse) were both observed cleaning Patient #C3, following a loose bowel movement.


An observation on the afternoon of 8/6/18 revealed Staff #C8, Telemetry tech assisting in the weighing of Patient #C3. Staff #C8 lifted and deliberately held Patient #C3's half full Foley catheter collection bag above the patient for approximately three minutes while the patient was being lifted on a Hoyer lift sling, allowing old urine to flow back into the patient, increasing the risk of infection.


Staff #C2, (CNA) was observed wiping stool off Patient #C3. Staff #C2 (RN) did not change her soiled gloves. Staff #C2 was then observed touching the patient's arm, hand, pillow, clean linens, the Hoyer lift sling, and the lift's control panel while wearing the soiled gloves.


Staff #C3, (RN) was observed wiping stool from Patient #C3's legs and cleaning the patient's perineal area. Staff #C3 did not wipe the Foley catheter tubing clean. Continuing to wear the same soiled gloves, Staff #C3 was then observed accessing Patient #C3's central catheter line, attaching a syringe, and flushing the patient's catheter line with normal saline, attaching a cap to the opened catheter port and then capping the intravenous fluid line. Staff #C3 stated, "I need to come back and do more Peri-care." Dark green residue was noted on the Foley catheter's access port. Staff #C3 left the patient unclean.


During an interview on the afternoon of 8/6/18, in the facility conference room, Staff #C3, RN, confirmed the finding.


Review of the facility provided policy Central Venous Access Device Care and Maintenance (dated 4/2018) reflected, " ... Flushing Central Venus Access Devices ...Wash hands with antimicrobial soap and put on clean gloves. 2.) Use aseptic technique and observe standard precautions throughout the procedure ...."


Review of Patient #C3's medical record reflected a 22-year-old female admitted on 7/27/18 status/post motor cycle collision with a right craniotomy, compressions fractures, laminectomy, left tibia ulna and radius fracture, and 5-8 rib fractures. The initial nursing assessment reflected, Patient #C3 was incontinent of bowel and bladder. The initial physician's orders dated 7/27/18 did not show an order for the insertion of a Foley catheter. An observation on the afternoon of 8/6/18 revealed Patient #C3 with a Foley catheter urinary collection bag.


Review of the facility provided URINARY CATHETER-ASSOCIATED INFECTION PREVENTION POLICY (dated 9/2017) reflected, " ...Urinary catheterization is not indicated for: Incontinence, Immobility, Patient and HCW's convenience, obtaining urine specimen, Diuresis unless ordered by physician ...."


During an interview on the morning of 8/7/19, Staff #C4, CNO confirmed the findings.

Based on review of documentation and interview, it was determined that medical records in the facility are not being completed in a timely manner.


Findings were:


Facility policy entitled "Medical Record Documentation Requirements" stated in part "Telephone orders must be authenticated by the prescribing physician within 96 hours of receiving.


Patient #1Roster B (admitted 7/31/18) had the following unauthenticated physician orders:
7/31/18: 1 order, 8/2/18: 6 orders, 8/3/18: 1 order.


Patient # 4 Roster B (admitted 7/02/18) had the following unauthenticated physician orders:
7/5/18, 7/7/18 (2 orders), 7/13/18, 7/14/18, 7/23/18, and 7/25/18.


Patient # 6 Roster B (admitted 7/28/18) had a physician order with no signature dated 7/28/18.


Patient # 7 Roster B (admitted 7/25/18) had an unsigned physician order dated 8/3/18.


Patient # 8 Roster B (admitted 7/27/18) had an unsigned physician order dated 7/29/18.


Patient # 9 Roster B (admitted 7/12/18) had two unsigned physician orders dated 8/4/18. There was also a History and Physical, completed by a Nurse Practitioner and dated 7/25/18, was unsigned by the patient's physician.


The CEO and the Director of Nurses were interviewed during the afternoon of 8/6/18. They confirmed the above unauthenticated physician orders and admitted that the facility policy regarding authentication of verbal orders did not comply with state regulations.

Based on review of documentation and interview, it was determined that the interim Infection Control Nurse had no specialized training or certification in infection control.

Findings were:

Job Description entitled "Infection Preventionist/Employee Health Nurse" stated in part under "Position Qualifications" "Minimum Qualifications: Current, valid, and active license to practice as a Registered Nurse in the state of Texas required. Minimum 3 years of clinical experience in a healthcare facility required. Knowledge of epidemiology, microbiology, infectious disease and aseptic technique to include standard precautions required. CIC certification preferred. Current BLS certification required."

In an interview with Staff Member # 7 Roster A (DON and interim Infection Control Nurse) on 8/7/18, she stated that she had no specialized training in Infection Control.

Based on observation, staff interviews, and a review of documentation, the facility failed to ensure a system for identifying, reporting, investigating, and controlling infections and communicable diseases for patients was developed as the hospital failed to:

a) Implement action based on the results of infection control surveillance and identified hospital-acquired patient infections;

b) Provide access to hospital staff to a current list of state notifiable conditions required to be reported to the state health authority. Thus staff may not have been aware of communicable disease required to be reported to state authorities; and

c) Ensure maintenance of a sanitary hospital environment.

Findings were:


a) Implement action based on the results of infection control surveillance and identified hospital-acquired patient infections -

Facility policy entitled "Infection Prevention & Control Plan," last revised 04/2018, included the following:

"Mesa Hills Specialty Hospital shall establish and maintain an Infection Control Plan including appropriate policies and procedures for the surveillance, prevention, and control of infection that reflect the hospitals [sic] mission statement ...

OBJECTIVES

1. Develop a hospital wide infection prevention and control program whereby there is a reduced risk of Healthcare acquired infections.

2. Identify risks for the acquisition and transmission of infections agents on an ongoing basis.

3. Establish priorities and set goals for preventing the development of healthcare acquired infections within the hospital.

4. Implement goals to achieve the prioritized goals and strategies that have been identified ...

SCOPE ...

2. The hospital will report infection incidents through surveillance, prevention, and control information to: ...

B. Federal, state, and local public health authorities in accordance with law and regulation ...

3. The hospital will develop a prioritized risk analysis and develop strategies to reduce, eliminate or minimize the prioritized risks identified ...

6. The hospital identified risks for the transmission and acquisition of infectious agents throughout the hospital based on the following factors: ...

B. Hospital infection prevention and control data collected analysis

C. The care, treatment, and services provided in the population served ...

8. Surveillance activities are used to identify infection prevention and control risks pertaining to patients, LIPs (Licensed Independent Practitioners), staff, and visitors (as warranted) ...

SURVEILLANCE METHODS/ACTIVITIES

1. Surveillance data will be collected, aggregated, and analyzed. The data collected will be reported to The Infection Prevention and Control Committee.

2. Maintains surveillance of the patient environment (i.e., environmental rounds), collects data pertaining to healthcare-acquired infections, prepares a report of all findings and reviews data with the Infection Prevention and Control Committee. Reports findings to Infection Prevention and Control Committee, the Medical Executive Committee and the Governing Board ...

3. Management of the health-care acquired infection risk reduction and/or prevention process will be supported through facility-wide systems dedicated to the collection, interpretation, analysis and presentation of facility-specific data findings ...

H. Monitor laboratory reports for reportable diseases ...

RESPONSIBILITY AND SYSTEMS MANAGEMENT ...

The Infection Prevention and Control Committee meets monthly ..."


A review of the infection control meeting minutes for 2018 revealed general discussion of infection control issues. For example, the minutes of the meeting on 4/27/18 included a discussion of topics such as hand washing compliance, reduction of unnecessary lab screenings, and a listing of numbers of healthcare-acquired infections. Though the committee was to meet monthly, the last meeting was in May, 2018. A form entitled "Infection Control Risk Assessment," was an environmental rounding tool which the former Director of Infection Control was completing on a somewhat weekly basis. A review of these completed forms revealed rare findings.


A review of the listing of numbers of healthcare-acquired infections revealed no further investigation into the cause of the infections, or the actions implemented as a result which might address and prevent further such infections. They were simply a listing of numbers of healthcare-acquired infections at the facility.


In an interview with the Staff #B1, Director of Nursing, and Staff #B17, CEO, on the morning of 8/6/18 in the facility conference room, the Director of Nursing stated, "Our program is not robust. The former infection control person is no longer here ...We were going to start environmental rounding this week ...We're not really doing much with infection control right now, but as a result of the survey we just had, we're trying to put some things in place. The person in the position formerly took paperwork with her when she left. We currently have no formal surveillance program in place ..."


In a subsequent interview with Staff #B1, Director of Nursing, on the afternoon of 8/7/18 at 12:55 p.m. in her office, she stated, "We're completely aware that the previous infection control and quality findings were only reported as numbers. No action was ever implemented in relation to the numbers. The information wasn't interpreted or used."


b) Provide access to hospital staff to a current list of state notifiable conditions required to be reported to the state health authority. Thus staff may not have been aware of communicable disease required to be reported to state authorities.


During a tour of the facility on the morning of 8/7/18 with Staff #B5, Director of Maintenance, no posting of state notifiable conditions was located.


In an interview with the hospital Director of Nursing on the morning of 8/7/18 at 10:50 a.m. in the facility conference room, she stated she was unaware of the state listing of Notifiable Conditions. The facility had no policy which addressed notifying the State regarding communicable diseases and conditions for which reporting was required.


c) Ensure maintenance of a sanitary hospital environment -

Facility policy entitled "Safety Management Plan," last revised 2/2016, included the following:

"The hospital will be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. The condition of the physical plant and the overall hospital environment will be developed and maintained in such a manner that the safety and well-being of the patients are assured ...

The hospital will establish and maintain a safe, functional environment ...

Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment, and services provided ...Including storage space to meet patient needs ...Keeps furnishings and equipment safe and in good repair ...


A tour of Mesa Hills Specialty Hospital on the morning of 8/7/18 with Staff #5, Director of Maintenance, and Staff #1, Director of Nursing, revealed the following infection control issues:

- Ill-fitting and openings in ceiling tiles throughout the facility, including in patient supply central storage areas and patient care areas. Openings in ceiling tiles allow a portal into the area below for dust, debris and pests to enter which can contaminate items below.

- Large and small areas of broken laminate was found throughout the facility on furniture in patient rooms, around sinks, and in patient supply areas. Broken laminate exposes the permeable surface underneath and makes thorough cleaning impossible.

- The refrigerator in the patient nourishment area had a temperature log which consistently noted the temperature above the acceptable range in May and June 2018. There were additional such listings in July. No action was documented resulting from the out-of-range temperatures in May and June. There was no evidence that maintenance was notified, or that food items were removed. In addition, there was a thick layer of ice in the freezer which also poses an infection control risk. The refrigerator contained hospital-provided patient snacks and family food items.

- The ice machine had dark mold deposits on the clear plastic dispenser area. Water was dripping from the dispenser and the machine generally appeared to need cleaning.

- In the respiratory ABG (arterial blood gas) lab, there was again broken laminate on the cabinets, making thorough cleaning impossible. In addition, an air conditioning unit against the wall was dirty and had a broken plastic covering.

- Cracked floor tiles were found throughout the facility. These make thorough cleaning of the floor impossible.

- In room 501, an opening in the ceiling around the sprinkler head allowed for the entry of dirt, dust and pests. The ceiling appeared to be fairly new, but the opening had been left at the time of repair.

- In room 512, the room had been cleaned and was ready for patient use. The patient table still had an stain about an inch in diameter which appeared possibly to have been old coffee.

- In room 502, there was an anteroom area with a sink and cabinets. When two of the cabinets were inspected, the bottoms contained large areas of dirt and old stains.

The above findings were confirmed with Staff #B1 and Staff #B5 during the facility tour.

Based on observation, staff interviews and a review of documentation, the facility failed to ensure a system for identifying, reporting, investigating, and controlling infections and communicable diseases for patients was developed as the hospital failed to implement action based on the results of infection control surveillance and identified hospital-acquired patient infections.

Findings were:

Facility policy entitled "Infection Prevention & Control Plan," last revised 04/2018, included the following:
"Mesa Hills Specialty Hospital shall establish and maintain an Infection Control Plan including appropriate policies and procedures for the surveillance, prevention, and control of infection that reflect the hospitals [sic] mission statement ...
OBJECTIVES
1. Develop a hospital wide infection prevention and control program whereby there is a reduced risk of Healthcare acquired infections.
2. Identify risks for the acquisition and transmission of infections agents on an ongoing basis.
3. Establish priorities and set goals for preventing the development of healthcare acquired infections within the hospital.
4. Implement goals to achieve the prioritized goals and strategies that have been identified ...
SCOPE ...
2. The hospital will report infection incidents through surveillance, prevention, and control information to: ...
B. Federal, state, and local public health authorities in accordance with law and regulation ...
3. The hospital will develop a prioritized risk analysis and develop strategies to reduce, eliminate or minimize the prioritized risks identified ...
6. The hospital identified risks for the transmission and acquisition of infectious agents throughout the hospital based on the following factors: ...
B. Hospital infection prevention and control data collected analysis
C. The care, treatment, and services provided in the population served ...
8. Surveillance activities are used to identify infection prevention and control risks pertaining to patients, LIPs (Licensed Independent Practitioners), staff, and visitors (as warranted) ...
SURVEILLANCE METHODS/ACTIVITIES
1. Surveillance data will be collected, aggregated, and analyzed. The data collected will be reported to The Infection Prevention and Control Committee.
2. Maintains surveillance of the patient environment (i.e., environmental rounds), collects data pertaining to healthcare-acquired infections, prepares a report of all findings and reviews data with the Infection Prevention and Control Committee. Reports findings to Infection Prevention and Control Committee, the Medical Executive Committee and the Governing Board ...
3. Management of the health-care acquired infection risk reduction and/or prevention process will be supported through facility-wide systems dedicated to the collection, interpretation, analysis and presentation of facility-specific data findings ...
H. Monitor laboratory reports for reportable diseases ...
RESPONSIBILITY AND SYSTEMS MANAGEMENT ...
The Infection Prevention and Control Committee meets monthly ..."

A review of the infection control meeting minutes for 2018 revealed generally discussion of infection control issues. For example, the minutes of the meeting on 4/27/18 included a discussion of topics such as hand washing compliance, reduction of unnecessary lab screenings, and a listing of numbers of healthcare-acquired infections. Though the committee was to meet monthly, the last meeting was in May, 2018. A form entitled "Infection Control Risk Assessment," was an environmental rounding tool which the former Director of Infection Control was completing on a somewhat weekly basis. A review of these completed forms revealed rare findings.

A review of the listing of numbers of healthcare-acquired infections revealed no further investigation into the cause of the infections, or the actions implemented as a result which might address and prevent further such infections. They were simply a listing of numbers of healthcare-acquired infections at the facility.

In an interview with the Staff #B1, Director of Nursing, and Staff #B17, CEO, on the morning of 8/6/18 in the facility conference room, the Director of Nursing stated, "Our program is not robust. The former infection control person is no longer here ...We were going to start environmental rounding this week ...We're not really doing much with infection control right now, but as a result of the survey we just had, we're trying to put some things in place. The person in the position formerly took paperwork with her when she left. We currently have no formal surveillance program in place ..."

In a subsequent interview with Staff #B1, Director of Nursing, on the afternoon of 8/7/18 at 12:55 p.m. in her office, she stated, "We're completely aware that the previous infection control and quality findings were only reported as numbers. No action was ever implemented in relation to the numbers. The information wasn't interpreted or used."





33326

Based on observation, interview and record review the facility failed to provide care in a sanitary manner when,

a.) On 8/6/18 two staff members did not remove soiled gloves and wash their hands following Patient #C3's incontinence care, placing patients at risk for infection and cross contamination. One staff lifted a Foley catheter bag over the patient's body, allowing old urine to flow back into the patient, creating an increased risk of infection. (Staff #C2, C3 and C8)

b.) A staff member exited Patient #C14's room, known to have C-diff (Clostridium-difficile a spore forming organism), without removing their personal protective equipment and did not wear gloves or wash their hands with soap and water after touching dirty items in the room, placing other patients at risk of cross contamination and infection. (Staff #C5) Patient #C14, currently on Isolation precautions, was left unsupervised in the public hallway.

c.) A patient with C-Difficile was placed on an "Enteric Isolation". The facility was not using the required disinfectant for a patient with C-difficile to prevent the possible spread of infection, Staff #C3, CNA, did not know what type of disinfectant was required and the facility did not have a policy for the appropriate disinfectant for Enteric Isolation. (Patient #C14)

d.) The facility's Infection Control Program failed to identify and investigate the cause of hospital acquired infections for two (2) out of five (5) patients. (Patient #C3 and #C14)

e.) A patient room air conditioner had copious amounts of dirt and blackened dust on the internal vents, placing patients at risk for respiratory infections. (Room 503)

Findings:

a.) Observations made on the afternoon of 8/6/18 at 2:20 pm, on the inpatient unit, revealed Patient #3 receiving incontinence care. Staff #C2, Certified Nursing Assistant (CNA) and Staff #C3, RN (Registered Nurse) were both observed cleaning Patient #C3, following a loose bowel movement.

An observation on the afternoon of 8/6/18 revealed Staff #C8, Telemetry tech assisting in the weighing of Patient #C3. Staff #C8 lifted and deliberately held Patient #C3's half full Foley catheter collection bag above the patient for approximately three minutes while the patient was being lifted on a Hoyer lift sling, allowing old urine to flow back into the patient, increasing the risk of infection.

Staff #C2, (CNA) was observed wiping stool off Patient #C3. Staff #C2 (RN) did not change her soiled gloves. Staff #C2 was then observed touching the patient's arm, hand, pillow, clean sheets and the facility's Hoyer lift sling and the lift's control panel while wearing the soiled gloves.

Staff #C3, (RN) was observed wiping stool from Patient #C3's legs and cleaning the patient's perineal area. Staff #C3 did not wipe the Foley catheter tubing clean. Continuing to wear the same soiled gloves, Staff #C3 was then observed accessing Patient #C3's central catheter line, attaching a syringe and flushing the patient's catheter line with normal saline, attaching a cap to the opened catheter port and then capping the intravenous fluid line. Staff #C3 stated, "I need to come back and do more Peri-care." Dark green residue was noted on the Foley catheter's access port. Staff #C3 left the patient unclean and at risk for infection.

During an interview on the afternoon of 8/6/18, in the facility conference room, Staff #C3, RN
confirmed the finding.

Review of the facility provided policy Central Venous Access Device Care and Maintenance (dated 4/2018) reflected, " ... Flushing Central Venus Access Devices ...Wash hands with antimicrobial soap and put on clean gloves. 2.) Use aseptic technique and observe standard precautions throughout the procedure ...."

b.) Review of Patient #C14's medical records reflected an admission date of 7/18/18. On 7/28/28 the physician's orders at 6:40 pm reflected C-diff (+). The nurse's notes dated 7/28/18 reflected, " ...Patient placed on Contact Precautions due to stool cx (culture) results.
Patient #C14's room 507 had a sign on the door, "Enteric Precautions."

An observation on the afternoon of 8/6/18, on the facility's inpatient unit, revealed Staff #C5, RD (Registered Dietitian) entering room 507, there was an Enteric Isolation sign on the door. Staff #C5 donned a disposable gown but did not put on gloves. Staff #C5 carried in a lunch tray and moved items around on the patient's bedside table and removed the dirty breakfast tray from the room. Staff #C5 walked out of the room and down the hall past two patient's rooms wearing the isolation gown she had worn in the room. Staff #C5 reached the empty food cart, where she touched the closed carts door and placed the dirty tray in the cart and closed the cart with the contaminated hand. Staff #C5 went back into the isolation room and discarded the disposable gown. Staff #C5 did not wash her hands. Staff #C5 then went out to the nurse's station and to the staff lounge. Staff #C2, CNA was observed reaching for the contaminated food cart. The surveyor stopped the CNA from touching the cart and advised the nursing staffs of the contaminated areas.

An observation on the afternoon of 8/6/18 revealed Patient #C14 sitting in a wheelchair unsupervised in the public access hallway. The patient's elbow was observed resting on the chair rail.

Review of the facility provided policy ISOLATION PRECAUTIONS (dated 9/2017) reflected, "Mesa Hill Specialty Hospital will follow current CDC guidelines on the prevention and spread of infections through the use of isolation precautions based on disease transmission ... There are four types of isolation: Airborne Isolation Droplet Isolation, Contact Isolation and Strict Isolation used alone or combined for diseases that have multiple routes of transmission ... Standard Precautions apply to all patients receiving care in the facility ... Hand Hygiene --- perform hand hygiene after contact with contaminated items. Also perform hand hygiene between patients, before and after gloving or indicated by obvious contamination .... Limiting the movement of any patient with an infectious organism is very important in preventing the spread of infection .... If they need to be transported to another area the following are adhered to: ... Do not leave Isolation patients alone in a waiting area ...Use Contact Precautions for patients know [sic] or suspected to have serious illness easily transmitted by direct patient contact or contact with items in the patient's environment. Examples of such illness include ...Clostridium difficile ...."

Review of the facility provided policy Management of Patients with Clostridium Difficile (dated 9/2017) reflected "All healthcare staff will comply with the following guidelines in order to aide in the preventing the spread of Clostridium difficle [sic] " ... they should be placed on Strict Precautions .... C. Difficile, a spore-forming organism, can survive well in the patient care environment ... Clean all equipment after use with bleach wipes."

The facility did not provide a policy for Enteric Isolation.

c.) Observations on the afternoon of 8/6/19 on the inpatient unit revealed Alcohol based cleaning wipes in all the patient rooms.

During an interview on the morning of 8/6/19, on the inpatient unit, Staff #C2, CNA stated, " ...if they are on Contact Isolation, we use the wipes with the bleach." Room 505 was noted as being on Contact Isolation but a red and white, alcohol wipe was noted in the room. Staff #C2 stated, "I need to get that fixed."

During an interview on the morning of 8/6/19, at the nursing station, Staff #C6, Central Supply Director stated, "We only use the bleach wipes if the patient has C-Diff .... CNA #2 must have been confused ...." On the morning of 8/8/18 Staff #C6 stated, "If the patient is on C-diff precautions, the bleach wipes are kept in the patient's room."

During an interview on the afternoon of 8/6/18, at the nurse's station, Staff #C 9, CEO stated, "We keep the bleach wipes at the nurse's station ...." The nurse's station is approximately 20 feet from Patient #C14's room. The bleach wipes were not available or easily accessible to decontaminate items used in the room.

During an interview in the afternoon of 8/6/19, in the conference room, Staff #C4, CNO (Chief Nursing Officer) stated, " ...We have been without an infection control nurse, I've been trying to cover ...we realize the program is lacking ...We've been trying to find someone .... I want to have time to do staff training ...."

d.) Review of the facility provided policy INFECTION SURVEILLANCE (dated 9/2017) reflected, "Definition of infection: .... 2. Hospital acquired infections are those infections that emerge >48 hours after admission to the hospital that were not present or incubating at the time of admission to the hospital ....
Responsibility:
A. The Infection Preventionist has the eventual responsibility for surveillance including data collection, evaluation and follow-up.
B. The nursing staff and other clinical services will help identify possible hospital acquired infection candidates for further investigation.
Data Collection:
A. Risk factors are identified and device days are noted.
B. Patients charts are audited for documentation, signs and symptoms of infections, positive culture reports ... antibiotic therapy .... when an infection was present on admit or a new infection occurs.

Review of Patient #C3's Microbiology results collected on 7/31/18 and resulted on 8/5/18 reflected " ...Greater than 100,000 colonies/ml. gram-negative rods and beta-hemalytic streptococci ... Pseudomonas aeruginosa, Enterococcus faecalis (found in the human lower intestinal tracts)
Review of Patient #C3's Physicians orders dated 7/30/18 reflected, "Temp 102, Zosyn IV (intravenous) 3.375 g (grams) q (every) 8 hours. Patient #C3's infection was not listed as being acquired in the facility.

Review of the facility provided Infection Prevention Log- Hospital Acquired Infections reflected Patient #C14 was admitted on 7/18/18 and was positive for C-diff on 7/28/18, ten days after admission. Patient #C14's infection was not listed as being acquired at the facility.

During an interview on the afternoon of 8/7/18, in the CNO's office, when asked did the facility currently have any hospital acquired infections Staff #4, CNO and acting Infection Control Preventionist stated, "We don't have any hospital acquired infections .... I haven't had a chance to review all the patient's medical records ...."

e. An observation on the morning of 8/8/18, in patient room 503, revealed the air conditioner front cover being removed by the maintenance director. The air conditioner's had copious amounts of blackened debris stuck to the internal vents and coils.

During a telephone interview on the morning 8/9/18, Staff #C9, maintenance director stated, "El Paso is very, very dusty. We only clean inside the air conditioners once a year .... I plan on changing that to twice a year." Staff#C9 confirmed the finding.