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Based on Quality Assessment Performance Improvement (QAPI) meeting minutes review, review of Quality Indicator Projects, and staff interview, the hospital failed to ensure all issues identified were analyzed, monitored, evaluated, solutions implemented, and failed to maintain an effective, ongoing, hospital-wide QAPI program.


1. On the afternoon of 12/30/2015, surveyors requested QAPI meeting minutes for the past 6 months and the current QAPI plan. Three binders titled Performance Improvement were provided. There was no documentation of a current QAPI plan.


2. On the morning of 01/04/2016, surveyors reviewed the QAPI meeting minutes and reviewed Quality Indicator Projects. There was no documentation in the QAPI meeting minutes or in the Quality Projects of problems being analyzed for a cause, there was no documentation problems were monitored, evaluated or solutions were implemented.


3. The QAPI meeting minutes and Quality Projects contained minimal documentation of possible plans of correction for problems identified but there was no documentation of how the problems were identified, there was no documentation that the plans of correction were implemented and there was no documentation plans of correction implemented were evaluated, and monitored. The Director of Quality Management told surveyors that problems are identified, analyzed, monitored, and evaluated. The Director of Quality Management told surveyors not everything was documented.


4. On the afternoon of 01/04/2016, surveyors requested the current QAPI plan. None was provided. The Director of Quality Management told surveyors the hospital did not have a current QAPI plan and she was currently developing one.

Based on infection control policy and procedure review, infection control surveillance review, personnel file review, and staff interview, the hospital failed to:


a. designate an infection control officer who was qualified through education, training, experience or certification; (see tag A-0748)


b. maintain an active infection control program for the prevention, control, and investigation of infections and communicable diseases; (see tag A-0749)


c. include all areas of the hospital in active surveillance; (see tag A-0749)


d. track and investigate employee illnesses; (see tag A-0749)


e. ensure all infection control surveillance data was incorporated into the Quality Assessment Performance Improvement Program; (see tag A-0756)


f. follow manufacturer's guidelines for endoscopic equipment management and high level disinfection; ( see tag A-0749)

Based on medical record review and staff interview, the facility failed to evaluate patients' health status on an ongoing basis.


Findings:


1. On the afternoon of 12/31/2015, surveyors reviewed patient medical records. The medical record for patient #11 indicated the patient was on a ventilator and on a continous Propofol (a drug used to slow the activity of the brain and nervous system) Intravenous (IV) infusion.


2. Patient #11 was on a Propofol drip from 12/07/2015 through 12/17/2015.


3. On the afternoon of 12/31/2015, surveyors reviewed a policy, titled, "Propofol (Diprivan) Continous Infusion Outside of the procedure/surgery area." The policy documented, "...Vital signs including cardiac rhythm, blood pressure, and oxygen saturation should be monitored and documented every 15 minutes to 1 hour during active drug titration and at least every hour when propofol is infusing..." The medical record of patient #11 did not contain documentation of the patient's oxygen saturation levels for 12/10/2015, 12/11/2015, 12/15/2015, and 12/17/2015.

Based on personnel file review and staff interview, the hospital failed to ensure nursing personnel had the appropriate skills and training for their assigned duties and in accordance with the needs of the patients.


Findings:


1. On the afternoon of 12/30/2015, administrative staff told surveyors Esophagogastroduodenoscopy (EGD) procedures were done at the facility for the placement of percutaneous endoscopic gastrostomy (PEG) tubes (a PEG tube allows nutrition, fluids and/or medications to be put directly into the stomach, bypassing the mouth and esophagus.) Administrative staff told surveyors nursing personnel assisted in the procedure. Administrative staff told surveyors there was a circulating nurse, a nurse who assisted the physician, and a sedating nurse all present during the procedure.


2. On the afternoon of 12/31/2015, surveyors reviewed sixteen nursing personnel files. None of the personnel files reviewed contained documentation of training for the EGD/PEG procedures.


3. On the afternoon of 12/30/2015, Staff O told surveyors that she was the only one who processed the endoscopes for the facility.


4. On the afternoon of 12/30/2015, surveyors reviewed the personnel file for Staff O. The personnel file contained no documentation of training of endoscope reprocessing.


5. On the afternoon of 12/30/2015, administrative staff told surveyors Registered Nurses (RN) initiate and titrate Intravenous (IV) drip medications.


6. On the afternoon of 12/31/2015, surveyors reviewed 10 RN personnel files. None of the RN personnel files reviewed contained documentation of training for IV drip medications.


7. On 12/31/2015, at 11:00 a.m., Staff P told surveyors that all Licensed Practical Nurses (LPN's) were trained to initiate Intravenous (IV) therapy.


8. On the afternoon of 12/31/2015, surveyors reviewed LPN personnel files. Three ( A, F, & L) of Seven LPN personnel files reviewed did not contain documentation of IV therapy training.

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


a. ensure routine and preventive maintenance was done on all patient care equipment;


b. to ensure the physical plant was maintained for patient safety.



Findings:


1. On the 12/30/2015, at 3:30 p.m., surveyors toured the hospital.


2. On the afternoon of 12/30/2015, Staff O was asked when the filters for the automated endoscope reprocessor were changed. Staff O told surveyors she had not been taught to change the filters. On the afternoon of 12/30/2015, at 4:35 p.m., surveyors reviewed a hospital document that had been provided to the hospital by the automated endoscope reprocessor manufacturer. The document was titled, "Filter Change Log." The log documented, "...the filters for each chamber of the machine should be changed each time the disinfectant solution was changed..." The log documented dates where the filters were changed and dates where the disinfectant was changed. The dates did not match.


3. Surveyors observed a patient/visitor dining area. There were divots in the floor in front of the ice maker. Staff O told surveyors there had been a water leak in front of the ice machine. Staff O told surveyors the water leak was fixed. Staff O told surveyors the hospital was going to fix the floor soon.

Based on Infection Control policy and procedure review, personnel file review, and staff interview, the hospital failed to designate an infection control officer who was qualified through education, training, experience, or certification.


Findings:


1. On the afternoon of 12/30/2015, administrative staff told surveyors staff O was the infection control officer. Administrative staff told surveyors Staff O was new to the position.


2. On the morning of 12/31/2015, at 9:20 a.m., surveyors reviewed the personnel file for Staff O. The personnel file contained no documentation Staff O was qualified through education, training, experience, or certification.


3. On the morning of 12/31/2015, at 11:00 a.m., Staff P told surveyors that Staff O had been given "hands on" training in infection control.

Based on infection control policy and procedure review, infection control surveillance review, observation, and staff interview, the hospital's infection control officer failed to ensure a system was in place for identifying, reporting, investigating, and controlling all infections and communicable diseases of patients and personnel.


Findings:


~ On the afternoon of 12/30/2015, administrative staff told surveyors Staff O was the infection control practitioner. Administrative staff told surveyors Staff O was new to the position.


~ On the afternoon of 12/30/2015, surveyors reviewed infection control policies and procedures. There was no documentation that the infection control practitioner had developed and implemented the infection control policies and procedures.


~ On the afternoon of 12/30/2015, Staff O told surveyors that she is involved in approving the use of all chemicals and disinfectants used in the hospital. There was no documentation that Staff O, the infection control committee, and medical staff had approved the use of all chemicals and disinfectants used in the hospital.


~ On the afternoon of 12/30/2015, Staff O told surveyors that she made environmental rounds of the hospital. Staff O told surveyors the dietary department and the laundry department are contracted services provided by the attached Nursing home. Staff O told surveyors she had not made environmental rounds in the dietary department or the laundry department.


~ On the afternoon of 12/30/2015, Staff O told surveyors she did not track and trend employee illnesses. Staff O told surveyors the hospital did not require the employees to give a reason why they call in sick for work. On the afternoon of 12/30/2015, surveyors reviewed a hospital policy titled, "Employee Health Evaluations." The policy documented, "...Employees with the following conditions must report to their department directors: Severe diarrhea lasting longer than 24 hours, Fever over 101, Acute Upper Respiratory infection or sever influenza, open draining wound, diagnosed strep (group A) sore throat, conjunctivitis, active infections with exposure to Hepatitis, HIV, Measles, Mumps, Rubella, Chicken Pox, Shingles, and TB..."


~ On the afternoon of 12/30/2015, and the morning of 12/31/2015, surveyors reviewed infection control meeting minutes and infection control surveillance data. There was no documentation of infection control problems identified with corrective actions taken.
There was no documentation of a Tuberculosis (TB) Risk Assessment. Staff O told surveyors there was not a TB Risk Assessment.


~ On the afternoon of 12/30/2015, at 3:25 p.m., surveyors toured the endoscopic re-processing room (decontamination room). Surveyors observed a double sink in the decontamination room. The sink was used to pre-wash the endoscopes. There was no handwashing sink in the decontamination room.


~ On the afternoon of 12/30/2015, Staff O told surveyors that she was responsible for re-processing the endoscopes. Staff O told surveyors she received endoscopic re-processing training from a previous staff member. On the afternoon of 12/30/2015, surveyors reviewed Staff O's personnel file. Staff O's personnel file contained no documentation of endoscopic re-processing training.


~ On the afternoon of 12/30/2015, Staff O told surveyors she did not use an air water cleaning adapter to pre-clean the endoscopes after a procedure. According to the Olympus manufacturer guidelines 2015, "immediately following the patient procedure...to prevent clogging of the air/water nozzle of the endoscope, flush water into the air/water channel of the endoscope, using the air water channel cleaning adapter..."


~ On the afternoon of 12/30/2015, Staff O told surveyors after a procedure she would hand carry the contaminated endoscope from the bedside down the hall into the decontamination room. According to the (AORN) Association of periOperative Registered Nurse (2013,) "during transport to the decontamination area, soiled flexible endoscopes must be contained to prevent exposure..."


~ On the afternoon of 12/30/2015, Staff O told surveyors she did not check the temperature of the Cidex OPA (high level disinfectant) before using it. According to the Cidex OPA instruction manual, the high level disinfectant should be maintained at a minimum of 25 ° C. Staff O told surveyors that she was not aware that the temperature of the Cidex OPA should be checked.


~ On the afternoon of 12/30/2015, surveyors observed a room in the Physical Therapy Department that was labeled as "Emergency Room." Surveyors observed a cabinet in the corner of the room where the endoscope was stored. Staff O told surveyors that the endoscope stayed in the cabinet until the next procedure. Staff O told surveyors the hospital did not have a process in place to re-process endoscopes at anytime prior to use. According to AORN (2013), flexible endoscopes should be reprocessed before used if stored for more than 5 days.


~ Surveyors observed in the room labeled "Emergency Room" an endoscopic light source with a liquid filled water bottle attached to the light source. Staff O told surveyors the liquid in the bottle is tap water. Staff O told surveyors the bottle is cleaned at the end of procedures with dawn dishwashing liquid. According to the (ASGE) American Society for Gastrointestinal Endoscopy (2011), sterile water should be used in irrigation bottles for all endoscopic procedures and reusable water and irrigation bottles should be manually cleaned and high level disinfected or sterilized after used.


~ On the afternoon of 12/30/2015, Staff O was asked when the filters for the automated endoscope reprocessor were changed. Staff O told surveyors she had not been taught to change the filters. On the afternoon of 12/30/2015, at 4:35 p.m., surveyors reviewed a hospital document that had been provided to the hospital by the automated endoscope reprocessor manufacturer. The document was titled, "Filter Change Log." The log documented, "...the filters for each chamber of the machine should be changed each time the disinfectant solution was changed..." The log documented dates where the filters were changed and dates where the disinfectant was changed. The dates did not match.


~ On the afternoon of 12/30/2015, Staff O told surveyors the hospital did not have any policies and procedures for reprocessing endoscopes.

Based on infection control meeting minute review, Quality Assessment Performance Improvement review (QAPI) , and staff interview the hospital leadership failed to ensure all infection control surveillance data was presented to the QAPI program and problems were identified with corrective actions taken.


Findings:


1. On the morning of 12/31/2015, surveyors reviewed the infection control meeting minutes. The infection control meeting minutes did not contain documentation of problems identified and corrective actions taken on the problems identified. On the morning of 12/31/2105, Staff P told surveyors infection control data is taken to the QAPI program.


2. The infection control meeting minutes did not contain documentation that all Hospital Acquired Infections (HAI) were identified with corrective actions taken.


3. The infection control meeting minutes did not contain documentation that all problems identified through infection control surveillance were identified with corrective actions taken.


4. On the morning of 01/04/2016, surveyors reviewed QAPI meeting minutes. The QAPI meeting minutes did not contain documentation that all infection control problems were identified with corrective actions taken.