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Based on review of Governing Body Meeting Minutes from January 2015 through October 2015 and interview, it was determined the facility failed to ensure the Governing Body approved the number of QAPI (Quality Assessment/Performance Improvement) projects to be conducted and the frequency with which they were to be monitored annually. The failed practice did not ensure the Governing Body was responsible for the QAPI program in the facility, and had the potential to affect any patient in the facility. Findings follow.

A. Review of Governing Body Meeting Minutes from January 2015 through October 2015 revealed the Governing Body did not approve QAPI indicators and monitoring frequency.
B. During an interview on 01/26/16 at 1005, the Administrator confirmed the Governing Body did not approve the QAPI indicators and monitoring frequency.

Based on review of Governing Body Meeting Minutes for January 2015 through October 2015 and interview, it was determined the facility failed to ensure the Governing Body determined which QAPI (Quality Assessment/Performance Improvement) projects were to be conducted; and failed to ensure a QAPI plan was approved annually by the Governing Body. The failed practice did not ensure the Governing Body was responsible for the QAPI program in the facility, and had the potential to affect any patient in the facility. Findings follow.

A. Review of Governing Body Meeting Minutes for January 2015 through October 2015 revealed no evidence the Governing Body had determined which QAPI projects were to be conducted and there was no evidence the Governing Body had annually approved a QAPI plan.
B. During an interview on 01/26/16 at 1005, the Administrator confirmed the Governing Body had not determined which QAPI projects were to be conducted; there was no evidence a QAPI plan was approved by the Governing Body.
C. During an interview on 01/26/16 at 1010, the Administrator confirmed the facility did not have a QAPI plan.

Based on observation, review of facility policies, review of manufacturer recommendations and interview, it was determined the facility failed to follow manufacturer directions in that one of one Tuberculin Purified Protein Derivative (PPD) was observed opened but not dated therefore, the 30 day expiration date could not be determined as required by manufacturer. The failed practice did not assure the safety or efficacy of the medication past 30 days once opened. The failed practice had the likelihood to affect all employees/patients at the facility. Findings follow:

A. During a tour of the facility on 01/25/16 from 1341 to 1445, revealed a vial of Tuberculin PPD in the medication refrigerator opened and not dated.
B. Review of policy titled Multiple Dose Vial Usage stated "Once entered, multiple dose vials will not be used after 28 days from the date of entering the vial unless specifically indicated otherwise by the manufacturer. The expiration date will be indicated on the vial once the vial is entered."
C. Review of manufacturer's recommendation for storage of Tuberculin PPD revealed "A vial of Tubersol which has been entered and in use for 30 days should be discarded because oxidation and degradation may have reduced the potency. Failure to store and handle Tubersol as recommended will result in a loss of potency and inaccurate test results. Do not use after expiration date."
D. During an interview on 01/25/16 at 1355, the Director of Nursing verified the Tuberculin PPD was opened, available for use, and not dated to indicate when it was opened.

Based on observation and interview it was determined the infection control officer failed to ensure gait belts and a transfer board was cleaned and disinfected between patient uses and the Foley catheter tubing was not lying on the floor. Failure to clean equipment between patient use had the potential for cross contamination between patients, staff and visitors. Failure to ensure the Foley catheter tubing was not on the floor had the potential for contamination of the urinary system. The failed practice affected all patients whose care required the use of gait belts, transfer belts and Patient #31. Findings follow:

A. During observation of Patient #9's therapy at 1400 on 01/25/16, Physical Therapy Technician #1 was observed to remove the gait belt from Patient #9 and return it to a rack containing other gait belts without cleaning it first. Physical Therapy Technician #1 was observed to utilize a transfer board to assist Patient #9 in moving from the Nu Step to the wheelchair. Physical Therapy Technician #1 was observed to return the transfer board to the cabinet containing other equipment without cleaning it first.
B. During an interview with the Director of Therapy at 1415 he stated, the gait belts should be sprayed with disinfectant after each patient use and allowed to dry, and the transfer board should have been cleaned with Virex prior to returning it to the cabinet.
C. During gym observations at 0915 on 01/27/16, Patient #31's Foley catheter tubing was observed to be lying on the floor. During an interview with Physical Therapy Technician #2 at 0925 on 01/27/16 he stated, the Foley catheter tubing was not supposed to be lying on the floor.


Based on observation, interview and policy and procedure review, it was determined the facility failed to ensure contact isolation precautions were followed for one of one (Patient #15) patient in isolation in that the facility failed to ensure the carts for contaminated linens and disposables were next to the door exiting the patient room. Failure to ensure the carts were next to the door allowed staff to cross the room without isolation protection to exit the room. The failed practice had the potential to affect all patients, visitors and staff in the facility. Findings follow:

A. During the tour at 1315 on 01/26/16, the carts for contaminated linens and disposables were placed in the middle of the wall under the TV. During an interview with the Infection Control Nurse at 1500 on 01/26/16, she verified the above findings.
B. Review of the policy and procedure titled "Guideline for Isolation Precautions in Hospitals" received from the Infection Control Nurse at 0930 on 01/25/16 the following was revealed: "B. Empiric Use of Airborne, Droplet or Contact Precautions ...4. CONTACT PRECAUTIONS, a Patient Placement, Place the patient in a private room. ... Regular patient rooms are adequate if isolation cart or equipment is placed directly outside the doorway and provisions are made for contaminated waste and isolation
linen." During the above interview with the Infection Control Nurse, she stated the carts for contaminated linens and disposables should have been placed by the exit door.


Based on observation, manufacturer's instructions and interview, it was determined two of two (Bottle 1 and Bottle 2) opened bottles of Accu Check control solutions did not have the date as to when they were opened to determine3 month expiration date. The failed practice did not assure the control solutions would provide the accurate test results. The failed practice affected all patients whose care required blood sugar checks. Findings follow:

A. Observation of the Accu Check control solutions bottle #1 and bottle #2 and review of the labels revealed the following manufacturer instructions: "Date opened: Discard 3 months after opening or after "Use by" date."
B. During an interview with Registered Nurse #1 at 1205 on 01/26/16, she verified the control solutions were not dated as to when they were opened.


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Based on observation, review of policy and interview, it was determined in the Rehabilitation Gym three (Walkers #1-3) of four (Walkers #1-4) in-patient walkers had duct tape on them which did not allow for cleaning and disinfection and three of three (Chairs #1-3) chairs used by patients were made with a fabric that could not be disinfected. The failed practice did not assure a sanitary environment when patients used the walkers and chairs. The failed practice had the likelihood to affect all patients that receive therapy services. Findings follow:

A. During a tour of Rehabilitation Services on 01/25/16 from 1300 to 1340, revealed three in-patient walkers were tored in the Rehabilitation Gym. The walkers had duct tape on them which did not allow for cleaning and disinfection. Observation also revealed three fabric covered chairs that patients used which could not be disinfected.
B. Review of policy titled Cleaning and Disinfection of Hospital Equipment stated Purpose: "Contaminated equipment is a major player in the transmission of nosocomial (hospital acquired) infections. Appropriate cleaning of patient care equipment after use and before reuse is extremely important for the safety of patients and staff by prevention of the transmission of disease." Also stated Policy: "Patient care equipment will be cleaned thoroughly by designated staff."
C. During an interview on 01/25/16 at 1320, the Director of Rehabilitation verified the three walkers had duct tape on them and the three chairs had fabric on them.