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Based on observation, staff interview, and document review, it was determined the hospital:

a. failed to provide experienced supervision of surgical services,

b. failed to provide surgical instrument sterilization according to standards of practice, and

c. failed to maintain appropriate pharmaceutical supplies in accordance to acceptable standards of practice.

This had the potential to affect all patients who had surgical procedures in the hospital.


Findings:


1. On 12/09/2015, at 10:30 a.m., the chief operating officer (COO) stated for the past two months, the hospital was without a director of surgery and that no actions had yet been taken to secure an experienced surgery director. The COO stated she was currently acting as the director of the surgery but did not have surgery experience.


2. During the course of the survey, surgical instrument sterilization records and hospital policies on sterilization practices were reviewed. A hospital policy, titled "Guides for Sterilization" documented, "... Bowie-Dick type indicator ... should be run ... each day in an empty sterilizer." According to nationally accepted standards of practice, this type of indicator test should be carried out each day before the sterilizer is used to process instruments in order to verify the sterilizer is functioning properly and that it adequately removed air during the sterilization cycle (ANSI/AAMI, 2013).


Sterilization records for September and October 2015 documented the staff who sterilized surgical instruments did not perform this test as directed by policy, but ran the test along with loads of instruments to be sterilized.


On 12/09/2015, at 11:15 a.m., the staff person responsible for sterilization verified that she sometimes included the Bowie-Dick test with loads of instruments to be sterilized. On 12/09/2015, at 2:15 p.m., the COO stated she was not aware the staff failed to perform sterilizer function tests as required by policy.


Immediate use steam sterilization (IUSS) records for September and October 2015 were reviewed. The records did not accurately reflect all the IUSS cycles performed. The hospital's "Flash Sterilization Record" had no documentation of an IUSS cycle performed on 10/05/2015; although a sterilization printout documented an IUSS cycle had been run. Staff Z stated the nurses who ran an IUSS cycle were responsible for documenting it on the flash sterilization record.


Some records of IUSS cycles were missing information. IUSS cycles run between 10/07/2015 and 10/26/2015 were missing information about sterilization dates, cycle times and temperatures. The cycle printouts were faded and the information about dates and cycle parameters could not be verified.


Current endoscope sterilization logs were reviewed. There was no documentation of the results of the chemical indicator necessary to verify successful sterilization. A hospital policy, titled "Central Sterile Cleaning and Usage of Endoscope Instruments," documented the staff were to document a pass or fail result for each endoscope sterilization cycle. On 12/08/2015, at 1:30 p.m., Staff Z stated the staff visually confirmed the sterilization but did not record it on the log.


On 12/09/2015, at 10:15 a.m., Staff Z stated the water bottles used during endoscopy procedures were rinsed with water at the end of the day and then air-dried. The hospital staff was asked to provide the manufacturer's instructions. The instructions documented, "Water bottles should be sterilized on a daily basis ... pre-vacuum temperature 270-279 degrees F, Time 5 minutes." The staff stated they were unaware of the manufacturer's instructions for processing the water bottles.


A hospital quality report, dated 09/30/2015, documented sterilization of surgical instruments was at 100% compliance. Infection control surveillance records for the surgery department, dated 10/22/2015, documented, " ... processes used for ... sterilization are in compliance with manufacturer recommendations and current nationally recommended standards ... YES."


On 12/09/2015, at 2:15 p.m., the COO stated she was not aware the staff failed to document all IUSS cycles and failed to verify that all sterilization cycles were performed within acceptable parameters and according to manufacturer's instructions.


3. 12/09/2015, at 10:30a.m., the surveyor reviewed the contents of the operating room's malignant hyperthermia cart. The cart contained six bottles of Dantrolene.


Malignant Hyperthermia Association's 2015 recommendations state 36 vials should be available in each institution where MH can occur.


12/09/2015, at 2:40 p.m., the pharmacist stated the decision to stock the malignant hyperthermia cart with six vials of Dantrolene was financially based due to its high cost.

Based on observation and staff interviews, the hospital failed to ensure patients received care in a safe setting.

Findings:
1. On December 8, 2015 12:00 p.m. surveyors toured the Geriatric Psychiatric Unit with the Director of the Unit. The following observations were made:

~ There were 10 hospital beds with long cords throughout the unit that the cords were not secured.

~ There were 10 hospital beds that plugged into the wall where the plugs could be easily removed and the electrical outlets were not secured.

~ There were 10 hospital beds throughout the unit that the cords could be used as a ligature (patients could use the cords to harm themselves or harm someone else).

~There were 10 patient rooms with beds/furniture that had wheels and were moveable. The patient doors to the bedroom swing inwards. There was no pass through to enter the patient room. Patients could move the beds/furniture and barricade the door. According to national standards of psychiatric practices and building design, patient doors should be out-swinging to prevent a patient from barricading themselves into a room.

2. On December 8, 2015 at 12:00 p.m., surveyors interviewed the Director of the Geriatric Psychiatric Unit. Surveyors asked the Director how the unit ensured patient safety with moveable furniture and potential for patients that could barricade themselves in a patient room. The Director of the Unit told surveyors she did not know how the facility would be able to get to the patient.

Based on review of Quality Assessment Performance Improvement (QAPI) meeting minutes and staff interview, the hospital failed to ensure all departments and services were included in the QAPI program.

Findings:
1. On December 8, 2015 at 11:50 a.m. surveyors requested QAPI meeting minutes. Administrative Staff provided QAPI meeting minutes. Surveyors reviewed QAPI meeting minutes. There was no documented evidence that discharge planning and organ procurement services were included.

2. On December 9, 2015 at 9:50 a.m. the Director of QAPI told surveyors there was no documented evidence of discharge planning or organ procurement in QAPI meeting minutes.

Based on review of medical records and policies and procedures and staff interviews, the hospital failed to ensure the discharge planning evaluation:

a. followed the hospital's discharge planning evaluation policy; and
b. included an evaluation of possible post-hospital services, care provided and equipment needed.

Findings:

1. The hospital's policy contained a pre-printed form to be used for the discharge planning evaluation. The hospital did not use the pre-printed form and relied on the computer program documentation. For five of five medical records (Records #8, 9, 11, 12 and 13), the computerized discharge planning evaluation did not contain all the components of the form contained in the hospital's discharge planning policy. The pre-printed form was not part of the medical records.

~ On 12/10/2015 at 1:10 p.m., Staff A stated the pre-printed discharge planning form was not part of the medical record and she did not utilized the form to ensure a complete discharge planning evaluation was completed.


2. The discharge planning evaluation did not include an assessment of the patient's post discharge care and equipment needs being met after discharge for Patient #3. The patient experienced shortness of breath and nebulizer treatments were part of the hospital treatment. The evaluation did not include whether a hand held nebulizer was available for patient use at home. This finding was confirmed with Staff A on 12/10/2015 at the time of review.

3. The discharge planning evaluation did not contain an assessment of the patient's ability to perform activities of daily living or for the care-giver to provide the services needed after discharge for Patient #2.

Based on hospital document review and staff interviews, the hospital failed to review the discharge planning for patients readmitted within 30 days on an ongoing basis to analyze whether the discharge plans and the discharge planning process met the patients needs.

Findings:

1. Hospital staff provided a list of patients that were readmitted to the hospital. The list provided tracked patient readmission dates and documented the reason for readmission.

~ On 12/08/2015 at 4:30 p.m. and on 12/10/2015 at 11:15 a.m., Staff X stated she only tracked and reported readmission, but no analysis or evaluation of the reason for readmission occurred.

2. Review of quality (QAPI) meeting minutes did not show the patient readmissions were analyzed to determine if:
a. The discharge plans met the patients needs after discharge;
b. Preventable readmissions could be identified; and/or
c. The discharge planning process needed to modified/changed.

3. On 12/10/2015, Staff C stated the hospital's discharge planning process was not part of QAPI.

Based on review of hospital documents and staff interviews, the hospital failed to incorporate organ procurement activities into the quality assessment and performance improvement (QAPI) program to ensure all deaths were reported to the organ procurement organization (OPO) within the time specified.

Findings:

Review of hospital QAPI minutes for the past year did not contain evidence organ procurement activities were reported and reviewed in QAPI.

On 12/10/2015 at 9:25 a.m., Staff C told the surveyors that organ procurement activities were not reported to QAPI.

Based on policy and procedure review, observation, and staff interview, the hospital failed to ensure emergency services personnel requirements were met.

Findings:
1. On December 9, 2015 at 2:30 p.m., surveyors toured and observed the emergency department (ED) waiting area and ED with Staff B and Staff C.

2. Surveyors observed registration personnel triaging patients. Registration personnel are not clinical.

3. Surveyors asked Staff QQ to explain the process of when a patient presents into the ED.

4. Staff QQ told surveyors, we ask the patient what they need to be seen for. If the patient looks real bad, says they are having chest pain, or trouble breathing we call the nurses in the back. If they look okay, we register the patient, tell the patient to sit in the waiting room and then bring the papers to the back where a nurse will come out to triage the patient when they are available.

5. Findings were verified by Staff B and Staff C immediately after Staff QQ's interview. Staff B and Staff C told surveyors that registered nurses with training are the only people qualified to triage patients presenting to the hospital.

6. On December 10, 2015 at 1:30 p.m., surveyors asked for the ED Triage policy and procedure. Staff C provided surveyors with a document titled, "Triage policy and procedure." The policy and procedure documented, "...The Registered Nurse will evaluate and categorize each patient upon arrival to the Emergency Department..."

7. Two (Staff QQ and RR) of two staff files reviewed showed no evidence of current ED clinical qualifications and competencies.

8. None of the records had documentation of verification of skills competencies related to clinical skills and specialized tasks in the ED.