HospitalInspections.org

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Radiology Services as evidenced by:

1) Failing to ensure there was a radiologist who was a member of the medical staff and supervised the radiology services and interpreted the radiological tests on either a full-time, part-time, or consulting basis (see findings in tag A-0546);

2) Failing to develop policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital by Company A (see findings in tag A-0546);

3) Failing to ensure radiology reports were signed/authenticated by the practitioner who performed the radiology service for 3 (#4, #26, #27) of 4 (#4, #26, #27, #29) sampled records reviewed for radiology services (see findings in tag A-0554).

Based on observations, record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Infection Control as evidenced by:

1) Failing to ensure a person or persons qualified through education, training, experience, or certification was designated as the infection control officer to ensure the development and implementation of policies governing the control of infections and communicable diseases; failing to implement isolation precautions; failing to develop and implement policies and procedures relevant to construction, renovation, maintenance, demolition, and repair; and failing to ensure Hand Hygiene practices were correctly and consistently implemented. (see findings at A-748).

2) Failing to ensure the infection control officers developed an effective system that included identification, reporting, investigation, and controlling of infections and communicable diseases of patients and personnel, as evidenced by failing to implement correct isolation precautions; failing to maintain a sanitary environment; and failing to have a policy and procedure in place to disinfect semi-critical instruments. (see findings at A-749).

3) Failing to ensure the QAPI program addressed infection control problems and implemented successful corrective action plans as evidenced by failing to conduct infection control surveillance of the hospital environment, collect data, track and trend and develop corrective actions plans resulting in observed infection control breeches at both campuses of the hospital and failing to implement successful corrective action plan to address breeches in hand hygiene at both campuses of the hospital. (see findings at A-756).

Based on interviews and record reviews, the Governing Body failed to ensure that the Governing Body assessed the hospital's Contract Services to identify quality and performance problems and/or implement appropriate corrective or improvement activities to ensure the monitoring and sustainability of those contracted services. This failed practice was evidenced by no QAPI (Quality Assurance Performance Improvement) quality assurance indicators, that were approved by the Governing Body, for the hospital's contracted services. The hospital had a total of 40 Contract Services listed in their Contract Service Manual.

Findings:
A review of the hospital's Contract Service Manual, provided by S1ADM (Administrator), as the most current, revealed a "Contract Service Review and Recommendation" form for each contracted hospital service. The "Contract Service Review and Recommendation" form included the name of the contract company, the type of service provided, when the agreement was signed, the date the contract was reviewed, and the renewal recommendation (to continue or discontinue the contract) and was signed by the Administrator and the Medical Director. A further review of the hospital's Contract Service Manual revealed no other documentation that identified quality assurance indicators/monitoring activities that evaluated the contracted services.

A review of the Governing Body meeting minutes from 4/25/13 to present revealed no documentation that identified quality assurance indicators/monitoring activities or quality assurance indicators, approved by the Governing Body, that evaluated the hospital's Contracted Services.

In an interview on 10/28/14 at 3:30 p.m. with S2DON (Director of Nursing), he indicated that he was the interim Quality Assurance co-coordinator until S6RN/IC/QA (Registered Nurse, Infection Control/Quality Assurance) completed orientation. S2DON was asked about the QAPI's quality assurance indicators for the hospital's Contract Services. S2DON indicated that the MEC (Medical Executive Committee) and the Governing Body discussed Contracted Services at the meetings. S2DON indicated that he was not aware of any QAPI quality assurance indicators for the hospital's Contract Services. S2DON further indicated he was not aware of any quality assurance indicators that were approved by the Governing Body to evaluate the hospital's Contracted Services.

In an interview on 10/28/14 at 4:00 p.m. with S1ADM, he indicated that he was a member of the Governing Body. S1ADM was asked about the QAPI's quality assurance indicators for the hospital's Contract Services that were approved by the Governing Body. S1ADM indicated that the Governing Body used a "Contract Service Review and Recommendation" form for the contracted hospital services that were evaluated at the Governing Body meetings. S1ADM indicated that a contracted service would be discussed at the Governing Body meetings, and if no Governing Body member had any issues/concerns with that contracted service, then the Governing Body would recommend that the contracted service be continued. S1ADM indicated that there were no QAPI quality assurance indicators approved by the Governing Body for the hospital's Contract Services.

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Based on interview and record reviews the Governing Body failed to ensure that the hospital had a system in place to evaluate the quality of the hospital's Contract Services to assure that each contracted service was provided in a safe and effective manner. This failed practice was evidenced by no QAPI (Quality Assurance Performance Improvement) quality assurance indicators for contract services that were implemented and approved by the Governing Body for any of the hospital's Contract Services, to evaluate the contracted services for quality and performance. The hospital had a total of 40 Contract Services listed in their Contract Service Manual.

Findings:
A review of the hospital's Contract Service Manual, provided by S1ADM, as the most current, revealed a "Contract Service Review and Recommendation" form for each contracted hospital service. The "Contract Service Review and Recommendation" form included the name of the contract company, the type of service provided, when the agreement was signed, the date the contract was reviewed, and the renewal recommendation (to continue or discontinue the contract) and was signed by the Administrator and the Medical Director. A further review of the hospital's Contract Service Manual revealed no other documented evidence that identified quality assurance indicators/monitoring activities to evaluate the contracted services.

A review of the Governing Body meeting minutes, from 4/25/13 to present, revealed no documented evidence that identified quality assurance indicators/monitoring activities that evaluated the hospital's Contracted Services were implemented.

In an interview on 10/28/14 at 4:00 p.m. with S1ADM, he indicated that he was a member of the Governing Body. S1ADM was asked about the QAPI's quality assurance indicators for the hospital's Contract Services, that were approved by the Governing Body. S1ADM indicated that the Governing Body used a "Contract Service Review and Recommendation" form for the contracted hospital services that the Governing Body evaluated at their meetings. S1ADM indicated that a contracted service would be discussed at the Governing Body meetings, and if no Governing Body member had any issues/concerns with that contracted service, then the Governing Body would recommend that the contracted service be continued. S1ADM indicated that there were no QAPI quality assurance indicators for the hospital's Contract Services. S1ADM further indicated that the Governing Body had no system in place to evaluate the quality of the hospital's Contract Services to assure that each contracted service was provided in a safe and effective manner.

Based on interview and record review, the hospital failed to ensure that the list of Contracted Services utilized by the hospital was updated and current. This failed practice was evidenced by no documentation of a complete and current Contract Services list maintained by the hospital. The hospital had a total of 40 Contract Services listed in their Contract Service Manual.

Findings:
A review of the hospital's Contract Service Manual, provided by S1ADM (Administrator), revealed approximately 40 hospital Contract Services on the list that provided services and/or patient care at both the hospital's main campus and the hospital's off-site campus.

In an interview on 10/28/14 at 4:00 p.m. with S1ADM, he was asked if the Contract Service list he (S1ADM) provided was the updated and current hospital Contract Services list that provided the services and/or patient care at both the hospital's main campus and the hospital's off-site campus. S1ADM indicated that the Contract Service list was not the most updated and/or current list. S1ADM further indicated that some of the Contract Services on the list he provided were no longer providing services and/or patient care at the hospital's main campus and/or at the hospital's off-site campus. S1ADM indicated that some of the Contract Services on the list he provided were replaced with other contract providers that were not listed on the Contract Service list.

Based on record review and interview the hospital failed to establish a process for prompt resolutions of patients' grievances as evidenced by the hospital's policy on grievances stating a response letter would be sent to a concerned party within 10 days if the grievance was filed after a patient was discharged from the hospital. Findings:

Review of the hospital's policy on Patient/Family Grievance in part, "....C. Complaint/Grievance Process Post-Discharge
1. In the event the Administrative Representative receives a complaint post discharge, then the complaint shall be handled as a grievance, as noted above in Section B. Grievance. An Event will be entered in the database and the appropriate manager will be notified for investigation.
2. Administration will be contacted and the issue will be reviewed and investigated within 10 days of receipt.
3. The Case Manager, DON (Director of Nurses) and/or Administrative Representative will send follow up letter to the concerned party regarding the concern and may follow-up with the patient via telephone..."

An interview was conducted with S2DON on 10/28/14 at 12:45 p.m. He reported he was in charge of handling grievances and complaints in the hospital. He verified, after reviewing the hospital's policy for Grievances and Complaints, that grievances that are filed after a patient was discharged didn't meet the federal regulation if the letter was sent to the concerned party within 10 days.

Based on record review and interview the hospital failed to ensure a written response to a grievance was provided for 1 out of 1 grievances that occurred in 2014. Findings:

Review of the policy for Complaints/Grievance Process Guidelines in part, "... 3. The Case Manager, Director of Nurses or the Administrative Representative will review the concern and note any additional steps taken to resolve the patient/family/representative's grievance. The Event Report is submitted to the Administrator. The patient/family/representative will be kept informed of all efforts made to resolve their grievance and will receive a written acknowledgement within 5 days of receipt form the hospital Administrator (designee)..."

Review of the Grievance Log revealed on 6/12/14 the daughter of Patient #10 sent a letter to the hospital's corporate office. Review of the letter revealed in part, "...My point to all this is, that it shouldn't have taken this long to get a death certificate signed. Someone should follow up to make sure all paperwork gets out properly and in a timely manner, not just reports..."

Review of the Grievance investigation report revealed in part, "...After investigation the form was found to be delayed due to the transfer of the deceased by two different nursing homes...Spoke with family member and expressed regret over...."

An interview was conducted with S2DON on 10/28/14 at 12: 45 p.m. He reported he was in charge of grievances and complaints. When questioned if a written response was sent to Patient #10's daughter regarding her grievance, he reported he spoke to the daughter on the phone, but was unaware a written response was required for grievances.

Based on observations and interview the hospital failed to provide care in a safe setting as evidenced by a 12 foot ladder and a 6 foot ladder leaning against a partial wall under construction in the therapy gym while therapy was occurring with patients. Findings:

Observations on 10/27/14 and 10/28/14, during the survey process, revealed two ladders in the therapy gym. During the course of the observations multiple patients were provided physical and occupational therapy in the therapy gym by the occupational and physical therapists. The gym was under construction with partial walls being constructed to partition off the gym into smaller rooms. During the course of the observations a 12 foot ladder was closed and leaning against one of the partial walls and a 6 foot ladder was open with a drill sitting on the top of the ladder on the other side of the gym.

Observations on 10/29/14, during the time of the survey, revealed the 12 foot ladder continued to be closed and leaning against the partial wall and the 6 foot ladder was now closed and leaning against the 12 foot ladder leaning against the partial wall.

An interview was conducted with S2DON on 10/29/14 at 4 p.m. and he verified the ladders were a safety hazard for patients.

Based on record review, observation, and interview the hospital failed to ensure the use of restraints were careplanned for 1 (Patient #1) out of 2 patients ( Patient #1 and Patient # 2) reviewed for the use of restraints. Findings:

Review of the hospital's policy titled Restraints revealed in part,"...5. Care Plan: The patient's care plan will be modified to reflect the need for restraint..."

Review of the medical record for Patient #1 revealed the patient was a 68 year old male with a medical history of throat carcinoma. The patient was found unresponsive in his home after undergoing radiation and chemotherapy the day before for treatment of neck and throat cancer. He was transferred to the current hospital on 10/24/14 for ventilator management/ weaning, physical, occupational and speech therapy, nutritional support, tracheostomy care, and management and monitoring of the patient's other complex and chronic medical conditions.

An observation occurred on 10/27/14 at 10 a.m. of Patient #1 in a bed with the siderails up and his wrists and ankles restrained with soft restraints. Patient #1 was moving in the bed attempting to reach his ventilator tubing and/or his Trach tube.

An interview was conducted with S19RN on 10/27/14 at 10 a.m. She reported she had called the physician for further orders and the patient was very agitated with the ventilator and the newly placed Trach tube.

Review of the medical chart revealed Patient #1 had physician orders for restraints on 10/25/14 through 10/27/14 at 0100 and there was documentation in the chart that restraints had been utilized during those time periods. There was no current physician order for restraints being utilized on the patient during the time of the observation.

Review of the patient's care plan reviewed the use of restraints on the patient was not in the plan of care for Patient #1.

An interview was conducted with S2DON on 10/27/14 at 1:10 p.m. He reviewed the patient's care plan and confirmed the use of restraints was not in the patient's plan of care and should have been added.

Based on observation, record review and interview the hospital failed to ensure a physician's order was obtained for use of restraints on 1 patient (Patient #1) out of a total of 2 patients (Patient #1 and #2) reviewed for the use of restraints. Findings:

Review of the hospital's policy on Restraints revealed in part, "...Restraint use will only be imposed upon receipt of appropriate physician orders, when needed to ensure the immediate physical safety of the patient, a staff member, or others and will be discontinued at the earliest time possible...Orders: Restraint use will be initiated upon the order of a physician or other licensed independent practitioner who is responsible for the care of the patient and authorized to order restraints. The order for the restraint will include the type of and site(s) of restraint to be applied and the specific actions or conditions that indicate restraints. The attending physician will be consulted as soon as possible if the attending physician did not order the restraint...Continuation of Restraint Orders: The attending physician or other licensed independent practitioner, who is responsible for the care of the patient, will perform in-person assessments of a restrained patient at least every 24 hours, at which time restraint will either be reordered or discontinued as indicated...."


Review of the medical record for Patient #1 revealed the patient was a 68 year old male with a medical history of throat carcinoma. The patient was found unresponsive in his home after undergoing radiation and chemotherapy the day before for treatment of neck and throat cancer. He was transferred to the current hospital on 10/24/14 for ventilator management/ weaning, physical, occupational and speech therapy, nutritional support, tracheostomy care, and management and monitoring of the patient's other complex and chronic medical conditions.

An observation occurred on 10/27/14 at 10:00 a.m. of Patient #1 in a bed with the siderails up and his wrists and ankles restrained with soft restraints. Patient #1 was moving in the bed attempting to reach his ventilator tubing and/or his Trach tube.

An interview was conducted with S19RN on 10/27/14 at 10:00 a.m. She reported she had called the physician for further orders and the patient was very agitated with the ventilator and the newly placed Trach tube.

Review of the medical chart revealed Patient #1 had physician orders for restraints on 10/25/14 through 10/27/14 at 0100 and there was documentation in the chart that restraints had been utilized during those time periods. There was no current physician order for restraints being utilized on the patient during the time of the observation or since 10/27/14 at 0100 (approximately for 9 hours).

An interview was conducted with S19RN on 10/27/14 10:15 a.m. She reported that she did not realize there was not a current restraint order for the patient.

Based on review of QAPI (Quality Assessment Performance Improvement) records and staff interview, the hospital failed to ensure the QAPI program was an ongoing program that showed measurable improvement in indicators as evidenced by failing to specify the method and frequency of data collection for the quality indicator of Blood Transfusions Administration.

Findings:

Review of the hospital's policy titled, Improving Organizational Performance Plan, policy number I.E.5.06 revealed in part the following: H. Hospital Departments:....The DON and department leaders will: ....2. Promote the development of pre-established standards of care and criteria to objectively measure the quality and safety of care/services rendered in their departments....The monitoring and evaluation process will include the following activities:....Blood Utilization.

Review of the QAPI data provided by S2DON (Director of Nursing) revealed Blood Transfusion Administration was reported as a percentage of compliance. Review of the Action Cue report for the last 12 months for the main campus revealed the compliance percentage for September 2014 was 96%. The benchmark (goal) was 98%. The percentages reported for the previous 12 months was 100%.

Review of the QAPI data revealed no documented evidence of the specific method and frequency of data collection for Blood Transfusion Administration. Review of the Performance Improvement Raw Data Binder provided for review revealed only copies of patient transfusion reports for the months of January through October, 2014. There was no documented evidence of the data collected or what aspects of Blood Transfusion Administration were tracked and trended. There was no documented evidence of the aspects of care that were not met.

In an interview on 10/29/14 at 1:25 p.m., the hospital's QAPI program was reviewed with S2DON. S2DON stated he reviewed the transfusion reports but he did not use an audit tool. S2DON confirmed there was no specific instructions for the method and frequency of the data collection for Blood Transfusion Administration. S2DON confirmed the September 2014 percentage of 96% was below the hospital's benchmark and stated the non-compliance was related to newly graduated nurses. S2DON confirmed he had no documentation of the data collected to support the finding of 96% compliance. S2DON confirmed the hospital had not done any corrective actions to address the failure to meet the benchmark in Blood Transfusion Administration.

Based on record review and staff interview, the hospital failed to ensure the QAPI program:
1) Used data collected to identify opportunities for improvement and changes that would lead to improvement as evidenced by failing to develop new corrective actions related to identified deficiencies in medical records after the same corrective action was unsuccessful, and;
2) Set priorities for performance improvement that focused on high-risk, high volume, or problem-prone activities as evidenced by the quality indicators selected at the corporate level.

Findings:

1) Used data collected to identify opportunities for improvement and changes that would lead to improvement as evidenced by failing to develop new corrective actions related to identified deficiencies in medical records after the same corrective action was unsuccessful:

Review of the hospital policy titled, Improving Organizational Performance Plan, policy number I.E.5.06 revealed in part the following: The Organizational Performance Improvement Plan of the hospital is designed to provide a systematic and organized program for the promotion of safe and quality patient care and services. Through an interdisciplinary and integrated process, patient care and processes that affect patient care outcomes shall be continuously monitored an devaluated to promote optional achievements, with appropriate accountability assumed by the Governing Board, Medical Staff, Administration, and support personnel.

Review of the medical records for Patients #4, #26, #27, and #29 revealed physician orders that were not timed and verbal orders that were not authenticated in accordance with the medical staff bylaws.

On 10/29/14 at 1:25 p.m., the hospital's QAPI program was reviewed with S2DON (Director of Nursing) who indicated he was the interim Quality Assurance co-coordinator until S6RN/IC/QA (Registered Nurse, Infection Control/Quality Assurance) completed orientation.
The quality indicator of Medical Record Entries Authenticated Timely was reviewed and revealed the following for 2014:
Main Campus Off-Site Campus
Jan - 83% Jan - 62%
Feb - 85% Feb - 71%
Mar - 86% Mar - 57%
Apr - 89% Apr - 79%
May - 67% May - 38%
June - 64% June - 31%
July - 71% July - 53%
Aug - 91% Aug - 92%
Sept - 83% Sept - 80%
Review of the documented corrective action plan to address the medical record deficiencies revealed education of the medical staff was the only intervention identified. S2DON confirmed the above findings, but stated he really was not familiar with what medical records was doing to address the medical record entries and suggested S7HIM (Health Information Management) could answer any questions regarding medical records.

In an interview on 10/29/14 at 2:20 p.m., S7HIM confirmed she was the Director of HIM and was responsible for the HIM QAPI. S7HIM confirmed the above percentages of medical record entries not authenticated timely. S7HIM stated she goes to the medical staff meetings and educates the physicians about dating/timing/authenticating entries and they improve for awhile. S7HIM stated the percentages go up and down and she goes back to the medical staff to educate again when the percentage drops. S7HIM confirmed the only corrective action implemented to address dating/timing/authentication of medical entries was educating the medical staff, she stated, "There is nothing else we can do."


2) Set priorities for performance improvement that focused on high-risk, high volume, or problem-prone activities as evidenced by the quality indicators selected at the corporate level.

Review of the hospital policy titled, Improving Organizational Performance Plan, policy number I.E.5.06 revealed in part the following: R. Facility Specific Monitoring: The hospital will continually strive to identify areas of opportunity for improvement. As new services are implemented or opportunities for improvement are identified and corrective action is initiated; the facility will design performance improvement monitors to assure achievement of facility goals. These facility specific monitors will be dynamic and changing throughout the course of the year. These results of these monitors will be reported to the QAPI Committee during the monthly meetings until the discontinuation of the monitor.

On 10/29/14 at 1:25 p.m., the hospital's QAPI program was reviewed with S2DON (Director of Nursing) who indicated he was the interim Quality Assurance co-coordinator until S6RN/IC/QA (Registered Nurse, Infection Control/Quality Assurance) completed orientation. When asked if the quality indicators being monitored were based high-risk, high volume or problem prone activities, S2DON stated the hospital's corporate office chose the quality indicators the hospital was to monitor. S2DON indicated he was unable to choose the quality indicators the hospital would monitor and stated the quality indicators were the same for all the corporation's hospitals. S2DON stated dated was collected and entered into the Action Cue software system and the system generated reports from the quality indicator data entered by the individual departments. S2DON stated the QAPI committee consisted of himself, S1ADM, S2ADON and the department heads and met once per quarter.

Based on observations, record review, and staff interview, the Chief Executive Officer, Medical Staff and Director of Nursing (DON) failed to ensure the QAPI program established clear expectations for patient safety as evidenced by:
1) failing to conduct infection control surveillance of the hospital environment, collect data, track and trend and develop corrective actions plans resulting in observed infection control breeches at both campuses of the hospital, and;
2) failing to implement successful corrective action plan to address breeches in hand hygiene at both campuses of the hospital;

Findings:

1) Failing to conduct infection control surveillance of the hospital environment, collect data, track and trend and develop corrective action plan resulting in observed infection control breeches at both campuses of the hospital environment:

Review of An Infection Control Surveillance Audit Form , provided by S2DON revealed, in part, blank forms that included an Infection Control Surveillance Audit Form. A place for the reviewer's name and month in review were provided. The Indicator was "Compliance with Hospital wide infection control practices, policies, and procedures." Instructions were: "Ongoing observations by ICN (Infection Control Nurse) and assigned Department Managers of the environment and interviews of staff. Minimum rounds 2x/week. May be in coordination with EOC (Environment of Care) rounds," Information for each entry was to be documented with date/time, areas(s) surveyed, Information of Staff initials, time of date, etc, and marked under Yes, No, or N/A columns, as well as the total number compliant and the total number of observations. The data points, or observations noted were:
-Visitors compliant with isolation precautions as posted including wearing of PPD (Personal Protective Equipment) and handwashing.
-Staff compliant with isolation precautions as posted including proper use of PPE, handling of linen and cleaning of medical equipment and supplies.
-Refrigerator temperature logs up to date without gaps or missing data. Reading outside range were reported and have action taken recorded.
-Clean and dirty supplies and equipment are kept separate. Clean and dirty areas visibly identified with appropriate signage.
-Sanitary environment is maintained free of dust, debris or potential contamination. Floor surfaces/furniture easily washable and clean.
-Isolation precaution signage is consistent with required precautions as result of cultures obtained.
-Isolation carts stocked with PPE and dedicated equipment per policy.
-Linen within room, and taken to and from isolation rooms properly handled and disposed of by caregivers.
-Patient family, visitors and staff demonstrated knowledge of the REASON for isolation
-Linen storage areas complaint with hospital policy, infection control practices and regulatory requirements.
-Patients infected or colonized with a multi-resistant organism and families received education about HAI (Healthcare Acquired Infections) prevention strategies.
-Hand Sanitizers available outside each room with sufficient product...
-Supply rooms neat and tidy. No boxes on the floor. Bottom shelves solid. 18" (inches) from sprinkler heads. No expired supplies.
-Nutrition room clean-refrigerator cleaned routinely. No expired food.
-Medical equipment "bagged and tagged"
Page 3 of 3 was blank and titled " Opportunities for Improvement. Be sure to date and time your notes."

Further review of Infection Control audit tools/forms provided by S2DON and S6RN/IC/QA revealed titled audit tools of Handwashing Observation Audit Form , Central Line Bundle (a group of evidence based interventions for patients with intravascular central catheters, that include hand hygiene, Maximal Barrier Precautions Upon Insertion, Chlorhexidine Skin Antisepsis, Optimal Catheter Site Selection, and Daily review of Line necessity with prompt removal of unnecessary lines)., Central Line Dressing Change, and CAUTI (Catheter Associated Urinary Tract Infection Event), and Environment of Care Rounds ( with Safety and Life Safety, Security, Equipment Management, Utilities, Hazardous Materials included).

In an interview 10/29/14 at 3:15 p.m., S2DON reported that after entering the data collected on the above surveillance and audit tools into an electronic program (Action Cue), the tools are disposed of and were not kept. S2DON further reported Performance Improvement reports from the Action Cue program showed percentages for each month,and compared the compliance percentage against other hospitals and benchmarks. S2DON, after reviewing Performance Improvement reports for Hand Hygiene Compliance with surveyors, agreed that one could not analyze the report for identification of problem areas, and therefore identify action plans to correct and monitor. Review of a Cleanliness of Facility Environment report revealed all "0" data for October 2013 through September 2014, verified by S2DON. S2DON stated the only monitoring done related to the cleanliness of the hospital environment was from the patient satisfaction surveys. S2DON verified no risk assessment or procedure had been developed or put into place regarding the present construction project in the Therapy gym. No raw data collected for infection control was provided.


2) Failing to implement successful corrective action plan to address breeches in hand hygiene at both campuses of the hospital:

Review of the QAPI records revealed hand hygiene was a performance measure of the infection control department and data was reported monthly by both campuses of the hospital. Review of the QAPI records revealed the hospital's benchmark was 85% compliance.
Review of the Hand Hygiene Compliance revealed the following for 2014:
Main Campus Off-Site Campus
Jan - 79% Jan - 86%
Feb - 80% Feb - 79%
Mar - 68% Mar - 75%
Apr - 83% Apr - 69%
May - 88% May - 71%
June - 96% June - 68%
July - 96% July - 77%
Aug - 90% Aug - 79%
Sept - 84% Sept - 82%

Review of the Action Cue report for Hand Hygiene Compliance revealed the only documented corrective action to addressed the staff non-compliance with hand hygiene was to educate and stress the importance of hand washing in staff meetings and install more sinks. There was no documented evidence of any further corrective actions to address hand hygiene.

In an interview on 10/29/14 from 1:25 p.m., S2DON confirmed he was the interim Quality Assurance co-coordinator until S6RN/IC/QA (Registered Nurse, Infection Control/Quality Assurance) completed orientation. After reviewing the Action Cue reports for Hand Hygiene Compliance for the last 12 months, S2DON stated he entered his documentation of hand hygiene surveillance onto the Action Cue system and then he destroyed the raw data. S2DON verified he had no documentation of any data collected related to hand hygiene. When asked what corrective actions had been done to address the failure to meet the identified benchmark of 85%, S2DON stated they educated and stressed to the staff the importance of hand washing and they had identified the need for additional sinks for handwashing. S2DON confirmed no new actions had been implemented to address the repeated lack of compliance with hand hygiene other than educating the staff. S2DON further stated no one person was responsible for overseeing QAPI. S2DON stated each department tracks their own QI and he did not know what they are tracking. When asked if he would be adding more infection control indicators, S2DON stated no, he, "Would like to", but it would have to be corporate wide and he could not add indicators in the Action Cue. S2DON stated AMG corporate chooses the quality indicators that the hospitals would track & trend.

Based on record review and staff interview, the hospital failed to ensure that it conducted performance improvement projects as part of its quality assessment and performance improvement program. The hospital could provide no documented evidence of a completed performance improvement project that it had conducted as well as an ongoing project.
Findings:

Review of the hospital policy titled, Improving Organizational Performance Plan, policy number I.E.5.06, effective date of 01/08/2013, revealed no documented evidence of any provisions for selecting and conducting performance improvement projects.

Review of the hospital QAPI (Quality Assessment Performance Improvement) records revealed no documented evidence of any performance improvement projects.

In an interview on 10/29/14 at 3:30 p.m., S2DON confirmed the hospital had not conducted any performance improvement projects and did not have an ongoing project in place at the present time.

Based on record reviews and interview, the governing body failed to ensure that the hospital's QAPI (Quality Assessment Performance Improvement) program reflected the hospital's organization and services as evidenced by not having all hospital departments and services including those services furnished under contract involved in the QAPI Program.
Findings:

Review of the hospital policy titled, Improving Organizational Performance Plan, policy number I.E.5.06, effective date of 01/08/2013, revealed in part the following:....B. Scope of Activities and Services....The scope of the Performance Improvement Program includes measurement and assessment activities which address patients served by the Medical Staff, Nursing, and ancillary services and hospital wide functions. Both clinical and non-clinical departments are included...

Review of the hospital's performance improvement records revealed no documented evidence that the hospital department of housekeeping was included in the QAPI program Further review of the QAPI documents revealed the contracted services of biomedical, blood bank, laundry/linen and biohazard waste disposal were not included in the QAPI program.

In an interview on 10/28/14 at 4:00 p.m. with S1ADM he indicated that he was a member of the Governing Body. S1ADM was asked about the QAPI's quality assurance indicators for the hospital's Contract Services that were approved by the Governing Body. S1ADM indicated that there was no specific QAPI's quality assurance indicators for the hospital's Contract Services.

In an interview on 10/29/14 at 4:00 p.m., S2DON (Director of Nursing) stated the QAPI nurse had been let go in June and he and S3ADON (Assistant Director of Nursing) had been doing the QAPI. S2DON stated S6RN/IC/QA (Infection Control/Quality Assurance) was hired a week ago and was going to be trained. S2DON confirmed that the above department and services were not included in the QAPI program. S2DON confirmed there were no quality indicators related to the above services or departments.

Based on record review and staff interview, the Governing Body failed to determine of the number of distinct improvement projects the hospital would conduct annually as evidenced by no perfomance improvment projects conducted in the last year or currently being conducted. Findings:

Review of the hospital policy titled, Improving Organizational Performance Plan, policy number I.E.5.06, effective date of 01/08/2013, revealed no documented evidence of any provisions for selecting and conducting performance improvement projects.

Review of the hospital QAPI (Quality Assessment Performance Improvement) records revealed no documented evidence of any performance improvement projects.

In an interview on 10/29/14 at 3:30 p.m., S2DON confirmed the hospital had not conducted any performance improvement projects and did not have an ongoing project in place at the present time.

Based on record reviews and interviews the hospital failed to ensure that the nursing staff developed and maintained a current nursing care plan, based on each patient's nursing care needs and not solely on those needs related to the admitting diagnosis, as evidenced by failing to develop comprehensive, individualized care plans for 6 of 6 (#4, #8, #26, #27, #29, #30) patients reviewed for care planning out of 30 sampled patients.

Findings:

A review of the hospital policy titled, "Plan of Care," provided by S2DON (Director of Nursing) as the most current, revealed in part: patient care plans will identify the main problems or potential problem areas that are patient specific including interventions and measurable goals. All interventions should be patient specific and will be personalized to meet individual patient care needs. The care plan will be reviewed each shift and revised as necessary. All nurses are responsible for updating the care plans.

Patient #4
Review of the medical record for Patient #4 revealed the patient was a 74 year old female admitted to the main campus on 09/26/14 with diagnoses of Ventilator Dependent, Pneumonia, Chronic Obstructive Pulmonary Disease, Anxiety, Depression, Diabetes Mellitus, Pressure Ulcer, and Congestive Heart Failure. Review of the physician's orders on admission revealed the patient was on sliding scale insulin, anxiety medications as needed, and Droplet Isolation Precautions.

Review of the Interdisciplinary Plan of Care revealed no documented evidence of any goals or interventions to address the patient's Diabetes Mellitus and sliding scale insulin. There was no documented evidence of any goals or interventions related to Anxiety. The care plan identified a nursing diagnosis of Risk of spread of infection and identified contact precautions as an intervention. There was no documented evidence droplet precautions were included in the plan of care. Further review of the care plan revealed no measurable goals or specific interventions related to the patient's pressure ulcer.


Patient #8
Patient #8 was a 66 year old male who was admitted to the hospital on 9/25/14 with a diagnosis of: graft infection. Patient #8 had a significant past medical history of PVD (peripheral vascular disease) and status post axillo-femoral bypass graft. The patient was admitted to the hospital for prolonged antibiotics, wound care, and monitoring of his chronic medical conditions. Patient #8's medical diagnoses included in part: hypertension, PVD, COPD (chronic obstructive pulmonary disease), diabetes, and late effects of a CVA (cerebral vascular accident).

A review of Patient #8's care plan revealed in part, the patient was care planned for: impaired mobility, decline in ADL's (activities of daily living), ineffective breathing pattern, pain, nutrition, urinary catheter, fall risk, skin integrity, and anxiety. There was no evidence in the patient's care plan that Patient #8 was care planned for diabetes, hypertension, or PVD.

In an interview on 10/28/14 at 11:00 a.m with S29LPN (Licensed Practical Nurse), she indicated that she had been caring for Patient #8. S29LPN was asked if Patient #8 had been care planned for diabetes, hypertension or PVD. Patient #8's care plan was reviewed in the presence of S29LPN. S29LPN indicated that there was no care plan initiated for Patient #8's diabetes, hypertension or PVD. S29LPN was asked if only RN's were allowed to update or revise patient care plans. S29LPN indicated that all nurses could update or revise a patient's care plan. S29LPN indicated that she was not aware that Patient #8's diagnoses of diabetes, hypertension, or PVD were not care planned, and that she had not updated or revised the patient's care plan to include his diagnoses of diabetes, hypertension or PVD.

In an interview on 10/28/14 at 11:15 a.m. with S2DON, he indicated that a patient's care plan should include all the patient's diagnosed medical conditions. S2DON indicated that all nurses were responsible for updating or revising a patient's care plan. S2DON further indicated that Patient #8's care plan should have included a care plan for diabetes, hypertension, and PVD.


Patient #26
Review of the medical record for Patient #26 revealed the patient was a 69 year old male admitted to the off-site campus on 10/14/14 with diagnoses of Respiratory Failure requiring Ventilator, Pneumonia, Infectious Pneumonitis, Dementia, PEG Tube, and Uncontrolled Seizures. Review of the physician's orders on admission revealed the patient was on sliding scale insulin and Contact Isolation Precautions. On 10/17/14 Droplet Precautions were also ordered for Stenotrophomonas in the patient's sputum culture. The record also revealed the patient had sacral excoriation on admission.

Review of the Interdisciplinary Plan of Care revealed no documented evidence of any goals or interventions to address the patient's contact and droplet isolation precautions. The care plan revealed High Risk for Infection and Risk for Spread of Infection were preprinted on the care plan form, but neither were checked as a problem for this patient. There was no documented evidence that the care plan included the monitoring of blood glucose and the use of the sliding scale insulin. There was no documented evidence of any goals or interventions related to impaired skin integrity.

In an interview on 10/28/14 at 2:45 p.m., S3ADON (Assistant Director of Nursing) reviewed the medical record for Patient #26 and confirmed the nursing care plan did not include all the patient's medical problems and the care plan was not individualized to include measurable goals and specific interventions.


Patient #27
Review of the medical record for Patient #27 revealed the patient was a 70 year old female admitted to the off-site campus on 10/14/14 with diagnoses of Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Degenerative Joint Disease, Uncontrolled Diabetes Mellitus and Morbid Obesity. Review of the physician's orders on admission revealed the patient was on sliding scale insulin.

Review of the Interdisciplinary Plan of Care revealed no documented evidence of any goals or interventions to address the patient's Uncontrolled Diabetes Mellitus or use of sliding scale insulin. There was no documented evidence of any goals or interventions related to Morbid Obesity.

In an interview on 10/28/14 at 2:45 p.m., S3ADON reviewed the medical record for Patient #27 and confirmed the nursing care plan did not include all the patient's medical problems and the care plan was not individualized to include measurable goals and specific interventions.

Patient #29
Review of the medical record for Patient #29 revealed the patient was a 54 year old female admitted to the off-site campus on 10/24/14 with diagnoses of Right Total Knee Replacement, Hypertension, Diabetes Mellitus and Chronic Obstructive Pulmonary Disease. Review of the physician's orders on admission revealed the patient was on sliding scale insulin.

Review of the Interdisciplinary Plan of Care revealed no documented evidence of any goals or interventions to address the patient's Diabetes Mellitus or use of sliding scale insulin.

In an interview on 10/28/14 at 2:45 p.m., S3ADON reviewed the medical record for Patient #29 and confirmed the nursing care plan did not address the patient's diagnosis of Diabetes Mellitus. S3ADON also verified the pre-printed check-off care plans used by the hospital did not include any nursing diagnosis, goals or interventions related to Diabetes Mellitus.


Patient #30
Review of the medical record for Patient #30 revealed she was a 63 year old female admitted on 10/22/14 to the hospital for Acute Iatrogenic Adrenal Insufficiency, Community Acquired Pneumonia, and E. coli urinary tract infection.

Review of a consultation report from S43MD Infectious Disease Specialist revealed the patient was referred to the Infectious Disease Specialist for suspected VRE (Vancomycin Resistant Enterococci).

Review of the patient's plan of care revealed no problem was identified on the plan of care related to infection.

An interview was conducted with S37LPN on 10/29/14 at 2:00 p.m. When S37LPN was questioned about Patient #30's diagnosis, she reported the patient was in contact isolation for VRE in her urine. With review of the plan of care with S37LPN, she confirmed there was no problem addressing the patient's infection in Patient #30's care plan.


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30172

Based on observation, record reviews, and interviews, the hospital failed to ensure the assignment of nursing personnel for patient care services was done in accordance with the nursing personnel qualifications and competence by failing to ensure the Unit Secretaries/Telemetry Monitor Technicians (Sec/MT) were assessed, evaluated, and deemed as competent for 4 (S25Sec/MT, S26Sec/MT, S27Sec/MT, S28Sec/MT) of 6 (S23Sec/MT, S24Sec/MT, S25Sec/MT, S26Sec/MT, S27Sec/MT, S28Sec/MT) nursing personnel assigned to monitor patients on telemetry. Findings:

Review of Policy Number: II.K.11.06, Telemetry Monitoring, revealed, in part, the following: "I. Policy: General Information: D. All telemetry patients will be monitored through a central monitor located at the nurse's station by a competency verified RN (Registered Nurse, LPN/LVN (Licensed Practical Nurse/Licensed Vocational Nurse) or monitor tech. II. Procedure: 1. Cardiac rhythms will be monitored by a qualified (person) at all times."

Review of Policy Number: I.B.2.23, New Employee Orientation revealed, in part, the following: "II. Procedure: 3. New employees should not be asked to perform skills, tasks, or functions for which they have not received orientation, and/or, for which their competency has not been validated."

Review of Policy Number: I.B.2.22, Staff Competency revealed, in part, the following: "I. Policy: In order to provide quality patient care, all employees shall be competent to fulfill their assigned responsibilities. Each member is assigned clinical and/or managerial responsibilities based on educational preparation, applicable State/Federal Licensing Laws and Regulations, and an assessment of current competence. An evaluation of a staff member's competence is conducted during the orientation process, three months post-employment and annually thereafter. The evaluation includes an objective assessment of the individual's performance in delivering patient care services and/or modalities in accordance with patient needs. II. Procedure: Competence assessment is an on-going process. Orientation. D. Initial skills checklist are completed by the clinical employees and reviewed by the appropriate supervisor. F. Conclusion of Orientation: 1. At the conclusion of the ninety day probationary period, the competency skills checklist is completed and reviewed with the employee's CCO (Chief Clinical Officer) or Department Director. 2. If there are concerns related to competence, the employee's orientation status may be extended with specific measures documented on needed improvements. III. Ongoing Competence, B. Documentation of Competence: 1. Competence will be documented on the company approved form and once completed will be placed in the employee's HR file. 2. Completed unit-specific competency checklist by the 3-month evaluation. At that time, if employee is found to be lacking in the knowledge or application of any skills listed the company will supply either education material or hands-on instruction to increase employee's competence."

An observation made on 10/27/14 at 1:30 p.m. revealed S28Sec/MT performing unit secretarial duties at the nurses' station and glancing occasionally at the telemetry monitor.

In an interview on 10/27/14 at 1:30 p.m., S28Sec/MT indicated she and/or the charge nurse were responsible for monitoring the telemetry screen for patients who were on telemetry. She also indicated she had not obtained any formal training or certifications for telemetry monitoring. S28Sec/MT indicated she was not able to identify all of the cardiac dysrhythmias, and she depended on the telemetry monitor alarms to sound if a patient was experiencing any cardiac dysrhythmias. S28Sec/MT further indicated she checked the alarms at the beginning of her shift to make sure they were functioning.

A review of S28Sec/MT's personal file revealed a conflict in her documented date of hire and the date on her Competency Based Orientation, Monitor Technician/Unit Secretary Form. S2DON reviewed the personnel file for S28Sec/MT and indicated her date of hire was 2/14/14. A review of S28Sec/MT's Competency Based Orientation, Monitor Technician/Unit Secretary form, dated 2/4/14 revealed, in part, under the section, Cardiac Dysrhythmias: Able to Recognize, with a listing of the dysrhythmias (Ventricular Fibrillation, Ventricular Tachycardia, Atrial Fibrillation, Atrial Flutter, Premature Atrial Contractions, Premature Ventricular Contractions, Paced Rhythms, Complete Heart Block, Pulseless Electrical Activity, and Systole) to be evaluated, a score of "A," which according to the document key, means "needs improvement" for all competencies evaluated under this section.
A review of the section "Able to Measure the Following Intervals: (PR, RS, QT)" revealed a score of "A" (needs improvement). There was no further documentation in S28Sec/MT's personnel file which indicated she was competent or qualified to perform telemetry monitoring for patients.
In an interview on 10/28/14 at 11:20 a.m., S2DON indicated he did not know why there was a discrepancy in the date of hire and the date documented on S28Sec/MT's competency assessment form. S2DON also indicated there was no method or requirement for the monitor technicians to check the telemetry system alarms at the beginning of their shifts. S2DON confirmed there was no further documentation in S28Sec/MT's personnel file which indicated she was competent or qualified to perform telemetry monitoring for patients, and she was not able to proficiently identify cardiac dysrhythmias and relied on the telemetry monitor alarms to sound if a patient were to experience a cardiac dysrhythmia. S2DON further confirmed S28Sec/MT needed further training, and S28Sec/MT should have received further training and been reassessed for skills and competence in telemetry monitoring. S2DON further confirmed he had not performed an assessment of S28Sec/MT's skills and competencies for telemetry monitoring,
A review of S25Sec/MT's personnel file revealed a document entitled Personnel Action Request Form (PAR) revealed S25Sec/MT's position was changed from a CNA (Certified Nursing Assistant) to a Unit Secretary/Monitor Technician with the effective date of change to be 5/26/13. Further review revealed no documentation of telemetry training or documentation of skills and competencies evaluations for telemetry monitoring. In an interview on 10/28/14 at 11:57 a.m., S2DON confirmed there was no documentation in S25Sec/MT's personnel file to indicate S25Sec/MT had received telemetry monitoring training and no documentation of an assessment of S25Sec/MT's skills and competencies for telemetry monitoring. S2DON further confirmed he had not performed an assessment of S25Sec/MT's skills and competencies for telemetry monitoring, and S25Sec/MT was likely dependent on the telemetry monitor alarms to sound if a patient were to experience a cardiac dysrhythmia.
In a telephone interview on 10/28/14 at 1:50 p.m., S25Sec/MT indicated she had received on-the-job training at the hospital for telemetry monitoring, but had not taken a formal telemetry monitoring course or received any type of certification.
A Review of S26Sec/MT's personnel file revealed a document entitled Personnel Action Request Form (PAR) revealed S26Sec/MT's position was changed from a CNA (Certified Nursing Assistant) to a Unit Secretary/Monitor Technician with the effective date of change on 4/28/13. Further review revealed no documentation of telemetry training or documentation of skills and competencies evaluations for telemetry monitoring.
In an interview on 10/28/14 at 12:20 p.m., S2DON confirmed there was no documentation in S26Sec/MT's personnel file to indicate S26Sec/MT had received telemetry monitoring training and no documentation of an assessment of S26Sec/MT's skills and competencies for telemetry monitoring. S2DON further confirmed he had not performed an assessment of S26Sec/MT's skills and competencies for telemetry monitoring, and S26Sec/MT was likely dependent on the telemetry monitor alarms to sound if a patient were to experience a cardiac dysrhythmia.
A review of S27Sec/MT's personnel file revealed a start date of 1/21/2010 for the position of Unit Secretary/Monitor Technician. Further review revealed no documentation on telemetry training and no documentation of an initial assessment of skills and competencies for telemetry monitoring. The initial orientation and competencies performed on 8/27/10 included general orientation topics, but did not include any skills or competencies specific for telemetry monitoring. Review of a form entitled Position Description/Performance Evaluation, dated 5/12/11, revealed the following indicator for assessing skills and competencies for telemetry monitoring, "Monitors and operates telemetry system. Admits and discharges from system" with a score of "M" for Meets the Standard." There was no documentation on the form to indicate who had completed the performance evaluation.
In an interview on 10/28/14 at 12:45 p.m., S2DON confirmed there was no documentation in S27Sec/MT's personnel file to indicate S27Sec/MT had received telemetry monitoring training and no documentation of an initial assessment of S27Sec/MT's skills and competencies for telemetry monitoring. S2DON verified there was no further documentation after the above referenced 5/12/11 evaluation, and S2DON also confirmed he had not performed an assessment of S27Sec/MT's skills and competencies for telemetry monitoring, and S27Sec/MT was likely dependent on the telemetry monitor alarms to sound if a patient were to experience a cardiac dysrhythmia.

Based on observations, interviews and record reviews, the hospital failed to ensure that patients' medical records were stored in locations where the medical records were protected from damage from water. This failed practice was evidenced by patient medical records being stored in dictation rooms (at both the main campus and the off-site campus) on open shelving racks in a room that had a sprinkler system.

Findings:
A review of the hospital policy titled "Storage of Medical Records" provided by S2DON (Director of Nursing), as the most current, revealed in part: Storage Space Specifications- storage space shall be selected to protect a patient's medical record from loss or destruction from hazards such as water damage.

An observation on 10/28/14 at 8:50 a.m. of the physician's locked dictation room at the off-site campus in the presence of S48HIM (Health Information Management) Clerk revealed 11 patient medical records stored on open shelving racks in a locked room that had a sprinkler system.

In an interview on 10/28/14 at 8:50 a.m. with S48HIM Clerk, she stated she placed incomplete discharged medical records in this dictation room for the physicians to complete. S48HIM Clerk stated there are always some incomplete records stored in this room. S48HIM Clerk verified the records stored in this room were not protected from water damage in the event the sprinkler system was activated.

An observation on 10/29/14 at 10:45 a.m of the physician's locked dictation room (main campus) in the presence of S7HIM, revealed 20 patient medical records being stored on open shelving racks in a room that had a sprinkler system.

In an interview on 10/29/14 at 11:00 a.m with S7HIM, she indicated that she placed discharged patients medical records in the dictation room (main campus) for the physicians to access so they could complete patient discharge summaries. S7HIM indicated that the patient medical records were sometimes stored in the dictation room for several days. S7HIM indicated that patient medical records stored in the dictation room (main campus) would not be protected from water damage if the sprinkler system was activated.



30172

Based on record review and staff interview, the hospital failed to ensure all orders, including verbal orders, were dated, timed and authenticated in accordance with medical staff bylaws for 4 of 4 (#4, #26, #27, #29) sampled patient records reviewed for physician order completeness out of a total sample of 30. Findings:

Review of the Medical Staff Rules and Regulations presented as current by S1ADM (Administrator) revealed in part the following: Section 5 Medical Record: Section 5.8.4 Medical orders will be accepted and transcribed in the patient's record by qualified personnel. The order shall include the date, time, and signature of the person taking the order and shall be countersigned by the prescribing practitioner....5.8.8 All orders must be dated, timed and authenticated by the ordering practitioner or another practitioner who is responsible for the care of the patient and authorized to write orders by this facility. 5.8.9 All verbal/telephone orders must be signed within 10 days.

Patient #4
Review of the medical record for Patient #4 revealed the patient was a 74 year old female admitted to the main campus on 09/26/14 with diagnoses of Ventilator Dependent, Pneumonia, Chronic Obstructive Pulmonary Disease, Anxiety, Depression, Diabetes Mellitus, Pressure Ulcer, and Congestive Heart Failure.

Review of the physicians' orders revealed the following:
09/26/14 verbal admission orders signed by the physician, but not dated or timed.
09/28/14 verbal orders for wound care not authenticated until 10/25/14, 27 days after the receipt of the order.
09/28/14 physician's order for medication and lab tests not timed by the physician.
09/29/14 physician's order for tracheostomy tube not timed by the physician.
09/29/14 wound care orders signed by the physician but not dated or timed.
10/01/14 physician's order to change tracheostomy tube not timed by the physician.
10/07/14 verbal order to change mattress not authenticated until 10/25/14, 18 days after the receipt of the order.
10/12/14 verbal order for ventilator weaning and blood gases not authenticated by the physician within 10 days of the order.
10/17/14 physician's order for medication not timed by the physician.
10/18/14 physician's order for lab tests not timed by the physician.
10/20/14 physician's order to discontinue the patient's catheter, not timed by the physician.

In an interview on 10/27/14 at 3:20 p.m., S2DON (Director of Nursing) reviewed the medical record for Patient #4 and confirmed the above orders were not dated or timed by the physician, and the above verbal orders were not authenticated in accordance with the medical staff by laws.

Patient #26
Review of the medical record for Patient #26 revealed the patient was a 69 year old male admitted to the off-site campus on 10/14/14 with diagnoses of Respiratory Failure requiring Ventilator, Pneumonia, Infectious Pneumonitis, Dementia, PEG Tube, and Uncontrolled Seizures.

Review of the physicians' orders revealed the following:
10/15/14 verbal orders PICC (Peripherally Inserted Central Catheter) Line placement not authenticated by the physician within 10 days of the order.
10/18/14 physician's orders for lab tests and medications not timed by the physician.
10/25/14 physician's order for blood cultures not timed by the physician.


Patient #27
Review of the medical record for Patient #27 revealed the patient was a 70 year old female admitted to the off-site campus on 10/14/14 with diagnoses of Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Degenerative Joint Disease, Uncontrolled Diabetes Mellitus and Morbid Obesity.


Review of the physicians' orders revealed the following:
10/15/14 verbal order for medications not authenticated by the physician within 10 days of the order.


Patient #29
Review of the medical record for Patient #29 revealed the patient was a 54 year old female admitted to the off-site campus on 10/24/14 with diagnoses of Right Total Knee Replacement, Hypertension, Diabetes Mellitus and Chronic Obstructive Pulmonary Disease.

Review of the physicians' orders revealed the following:
10/25/14 physician's order for medications and lab tests not timed by the physician.

In an interview on 10/28/14 at 5:00 p.m., S3ADON (Assistant Director of Nursing) reviewed the medical records for Patients #26, #27, and #29 and confirmed the above orders were not dated or timed by the physician, and the above verbal orders were not authenticated in accordance with the medical staff by laws.

Based on observation, record review, and interview, the hospital failed to ensure outdated medications and intravenous fluids were not available for patient use. Findings:

Review of a contract between the contracted pharmacy services revealed, in part, "(g) Provide Pharmacists for in-house visitation to the facility for the purpose of patient chart reviews, medication administration adherence checks, pharmacy medication intervention, and general pharmacy oversite."

Review of a policy for Intravascular (IV) Therapy revealed, in part, "All IV fluids are delivered and replenished daily and as needed to the nursing unit by contracted pharmacy personnel."

An observation in the medication supply room on 10/27/14 revealed the following items were expired and available for patient use: Four 1000 ml (milliliter) bags of 0.9% Sodium Chloride with 0.15% of Potassium Chloride IV solution (Expired 07/14); Two 1000 ml bags of 0.9% Sodium Chloride with 5% Dextrose and 0.15% Potassium Chloride IV solution (Expired 06/14); Five 1000 ml bags of 5% Dextrose with 0.15% Potassium Chloride IV solution (expired 07/14).

Further observation in the medication supply cart revealed: one multidose vial of Humalog U-100 insulin had an expiration date of 10/23/14 documented on the vial and was available for patient use; one multidose vial of Levemir insulin which had expired on 10/20/14 (puncture date documented as 9/23/14) and was available for patient use.

In an interview on 10/27/14 at 11:35 a.m., S2DON indicated the pharmacy service was responsible for delivering, replenishing, and removing all expired medications from the medication supply room. S2DON confirmed the above-referenced medications were expired and available for patient use and the medications should have been removed and not available for use for patients.

In an interview on 10/29/14 at 1:55 p.m., S36RPh/Dir (Pharmacy Director) confirmed the pharmacy service was responsible for removing expired medications and IV fluids from the medication supply at the hospital.

Based on record reviews and staff interview, the hospital failed to develop policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital by Company A. Findings:

Review of the contracts provided by S2DON revealed the hospital had a contract with Company A to provide mobile x-ray services.

Review of the hospital's policy and procedure manuals provided by S2DON as the hospital's current policies revealed no documented evidence of any policies and procedures related to radiology services.

In an interview on 10/27/14 at 3:30 p.m., S2DON was asked if the hospital had any policies and procedures for proper safety precautions against radiation hazards such as adequate shielding for patients and personnel and determining that a female patient was not pregnant prior to performing the procedure. S2DON was observed to contact Company A and request safety policies for radiology services. S2DON provided Company A's policies for shielding, pregnant workers, and patient holding.

In an interview on 10/27/14 at 4:05 p.m., S2DON confirmed Company A took the patient's x-ray when ordered in the hospital setting. S2DON confirmed the hospital had no policies and procedures related to radiology services or the safety of patients and personnel during x-ray tests. S2DON also indicated the only monitoring of the services provided by Company A was the turnaround time of routine and stat tests.

Based on record review and staff interview, the hospital failed to ensure there was a radiologist who was a member of the medical staff and supervised the radiology services and interpreted the radiological tests on either a full-time, part-time, or consulting basis.
Findings:

Review of the list of credentialed physicians on the Medical Staff, presented as a current list by S3ADON (Assistant Director of Nursing), revealed 28 physicians listed as consulting radiologists. There was no documented evidence that any of the consulting radiologists was identified as the Director of Radiology or the Supervising Radiologist.

Review of the contracts provided by S2DON (Director of Nursing) revealed the hospital had a contract with Company A to provide radiology services.

In an interview on 10/27/14 at 4:05 p.m., S2DON was asked for documentation of the appointment of the hospital's Director of Radiology. S2DON was observed to call Company A and request documentation of the Director of Radiology. S2DON provided a faxed copy of the Curriculum Vitae for S34Radiology/MD. S2DON confirmed S34Radiology/MD was the Director of Radiology for Company A.

Review of the credentialing record for S34Radiology/MD revealed the physician was privileged and credentialed as a consulting radiologist only. There was no documented evidence that S34Radiology/MD was appointed as the Director of Radiology for the hospital.

In an interview on 10/29/14 at 3:50 p.m. S2DON verified the hospital did not have a Director of Radiology services.

Based on interviews and record reviews, the hospital failed to ensure that the dietary service department maintained safe practices for food storage for food available for patient consumption. This failed practice was evidenced by incomplete temperature monitoring documentation on the patient refrigerator/freezer temperature log sheets maintained by the dietary department at the main campus of the hospital. The hospital had a census of 12 patients at the hospital's main campus with a total capacity for 20 patients.

Findings:
A review of the policy titled "Food Safety" provided by S2DON (Director of Nursing), as the most current, revealed in part: the dietary department shall maintain refrigerator/freezer temperature log records.

A review of the policy titled "General Refrigerator Cleaning" provided by S2DON, as the most current, revealed in part: refrigerator/freezer temperature logs are to be maintained and monitored by specific hospital units.

An observation on 10/28/14 of the patient nourishment area in the dietary department (main campus) revealed incomplete temperature monitoring documentation on the patient refrigerator/freezer temperature log sheets maintained by the dietary department. The refrigerator/freezer temperature logs revealed no documented evidence that the temperatures on the patient refrigerator/freezer in the patient nourishment area were recorded/monitored for the following days: February 2014 - no recorded temperature for 13 out of 28 days; March 2014 - no recorded temperature for 7 out of 31 days; April 2014 - no recorded temperature for 29 out of 30 days; May 2014 - no recorded temperature for 31 out of 31 days; June 2014 - no recorded temperature for 30 out of 30 days; July 2014 - no recorded temperature for 25 out of 31 days; September 2014 - no recorded temperature for 17 out of 30 days; October 2014 - no recorded temperature for 14 out of 27 days.

In an interview on 10/28/14 at 2:30 p.m. with S8RD (Registered Dietician) she indicated that she was the dietary manager for the hospital's main campus. S8RD was asked about the missing temperature monitoring documentation on the patient refrigerator/freezer temperature log sheets from February 2014 to present. S8RD indicated that she would monitor and document the refrigerator/freezer temperatures on the refrigerator/freezer temperatures log sheets whenever she worked. S8RD indicated that she was not present at the hospital's main campus everyday. S8RD further indicated that the nursing staff was responsible for monitoring and documenting the refrigerator/freezer temperatures on the log sheets when she was not present.

In an interview on 10/28/14 at 3:00 p.m. with S2DON, he was asked about the monitoring of the patient refrigerator/freezer temperatures in the patient nourishment area (main campus) and the documentation of the refrigerator/freezer temperatures on the log sheets. S2DON indicated that monitoring of the patient refrigerator/freezer temperatures in the patient nourishment area and the documentation of the patient refrigerator/freezer temperatures on the log sheets was the responsibility of the night CNAs. S2DON further indicated that the night CNAs were not compliant with that assigned task.

Based on observation, record review, and interviews, the hospital failed to ensure supplies and equipment were maintained to ensure an acceptable level of safety and quality. This was evidenced by:
1) There were expired infusion, injection supplies and Betadine swabs in the central supply closet available for patient use;
2) expired supplies on the crash carts on the main campus and the off-site campus available for patient use;
3) failing to ensure the functionality of a call button labled, "Nurse call" located on the handrails of the beds for all patient beds on the main campus and the off-site campus (20 beds at each site).

Findings:

1) Expired supplies in Central Supply Closet:
An observation was conducted of the central supply closet on 10/27/14 at 10:45 a.m. Approximately 100 catheter insertion kits with an expiration date of 09/14, a box of 18 gauge introcan safety catheters with an expiration date of 12/10, and 2 boxes of betadine swabs (50 in each box) had an expiration date of 3/14, all were available for patient use.

An interview was conducted with S9AdminAst/HR/DM/SS(Administrative Assistant, Human Resources, Sterile Supply) on 10/27/14 at 10:45 a.m. She reported she was in charge of maintaining and ordering supplies. She confirmed the introcan catheters, betadine swabs, and the catheter insertion kits were expired.

2) Expired supplies on the crash carts on the main campus and the off-site campus available for patient use:
On 10/27/14 at 11:20 a.m. an observation was made of the crash cart (Emergency supplies) on the main campus with the Charge Nurse (S18RN). The following supplies were found to be expired: 13 blood tubes, 2 IV (Intravenous) start kits, 1 introcan catheter, 4 packs of water soluble lubricant, Betadine swabs (2011), 3 Butterfly IV needles, 3 defibrillator pads (2009), 1 package of electrodes, and 3 packages of sterile gloves. S18RN stated the Charge Nurse was responsible for checking the crash cart and confirmed the above expired supplies were on the crash cart and available for patient use during an emergency.

On 10/28/14 at 9:40 a.m., and observation was made of the crash cart on the off-site campus with S3ADON. Expired blood tubes and a defibrillator pad was observed in the crash cart. S3ADON confirmed the expired supplies were available for patient use.



3) Failing to ensure the functionality of a call button labeled "Nurse Call" located on the handrails of the beds on main and off-site campuses:

Observations were made on the patient unit of the main campus of the hospital on 10/27/14 between 10:50 a.m. and 11:30 a.m. A button labeled "Nurse Call" was noted to be on the handrail of the beds on 20 of 20 patient beds. The button was noted to be non-functional as it failed to activate any type of nurse call system.

The Charge Nurse (S18RN) was interviewed at the time of this observation. S18RN confirmed that the button labeled "Nurse Call" located on the handrails of the inpatient beds was not functioning when pressed. S18RN confirmed all the beds in the hospital were the same and the side rails of all the beds contained the same "Nurse Call" button, and none of the side rail "Nurse Call" buttons were functional. S18RN indicated that the hospital does have a nurse call system which includes a cord with a button and reported that patients are instructed to use this call system. When asked if it would be possible for a patient who may be sedated and/or confused to press the button on the handrail of the bed labeled "Nurse Call" thinking they are calling for assistance without the nursing staffs knowledge due to the call button not working, S18RN indicated yes that would be possible.

Observations were made on the patient unit of the off-site campus of the hospital on 10/28/14 between 9:00 a.m. and 10:30 a.m. A button labeled "Nurse Call" was noted to be on the handrail of the beds on 20 of 20 patient beds. The button was noted to be non-functional as it failed to activate any type of nurse call system.

The Assistant Director of Nursing (S3ADON) was interviewed at the time of this observation. S3ADON confirmed that the button labeled "Nurse Call" located on the handrails of the inpatient beds was not functioning when pressed. S3ADON confirmed all the beds in the hospital were the same and the side rails of all the beds contained the same "Nurse Call" button, and none of the side rail "Nurse Call" buttons were functional. S3ADON indicated that the hospital does have a nurse call system which includes a cord with a button and reported that patients are instructed to use this call system. When asked if it would be possible for a patient who may be sedated and/or confused to press the button on the handrail of the bed labeled "Nurse Call" thinking they are calling for assistance without the nursing staff's knowledge due to the call button not working, S3ADON indicated yes that would be possible.



26351

Based on observations, record review and interviews, the hospital failed to 1) ensure a person or persons qualified through education, training, experience, or certification was designated as the infection control officer to ensure the development and implementation of policies governing the control of infections and communicable diseases; 2) implement isolation precautions; 3) develop and implement policies and procedures relevant to construction, renovation, maintenance, demolition, and repair, and; 4) ensure Hand Hygiene practices were correctly and consistently implemented.
Findings:

Review of hospital policy # III.R.18.00, titled Infection Control Plan, effective 8/21/12, and provided by S2DON (Director of Nursing) as current, revealed the following in part:
Introduction: "...To prevent the spread of communicable disease, this Hospital will administer an effective infection control program. The infection control program will operate under those standards set for by the Centers for Disease Control (CDC), Occupational Safety and Health Administration (OSHA), Joint Commission, and other federal, state, and local agencies. Uniform guidelines based on current evidence-based recommendations will be followed in order to protect patients, healthcare workers, visitors, and others at this Hospital...
Mission: Infection Control is the responsibility of all hospital personnel. The mission ...is done by: 1) working through concurrent Quality Assessments and Performance Improvement [QAPI] Program . 2) Performing ongoing risk assessments to identify the risk for transmission and acquisition of infectious agents in the hospital...4) Developing and implementing infection control policies.
Responsibility: A. Infection Control is everyone's responsibility. All levels of employees have a vested interest and a responsibility to ensure that the Infection Control Program is carried out. 1. Administration: supports the activities and function of the Infection Control Plan for the Hospital and provides necessary resources to implement the objectives of the plan.
2. Infection Control Coordinator (ICC): Works with department directors in reviewing and revising Infection Control Policies and procedures...,collects and analyzes data for Infection Control issues, evaluates the effectiveness of the Infection Control program...
3. Department Directors: Ensure adherence to Infection Control procedures by department personnel...
4. Employees:..Participate in quality improvement activities that relate to Infection Control, and follow and practice Infection Control principles in their job responsibilities...
E. Strategies to Minimize, Reduce, or Eliminate Risks: 1. Activities include...limitation of unprotected exposure to pathogens throughout the hospital through staff education, providing appropriate PPE and ensuring that appropriate isolation is being utilized. 2. Auditing hand hygiene practices among all caregivers including; nurses, therapist, Licensed Independent Practitioners, (LIP) is to be done quarterly. 3. Staff education on appropriate storage, cleaning/disinfection, and/or disposal of supplies and equipment.
Strategy Evaluation: 1. Strategies will be evaluated ongoing and on annual basis. 2. Strategies will be evaluated on their performance and effectiveness. 3. Strategies that have not been effective will be identified and addressed in the Performance Improvement Process.

Review of hospital policy # III.R.18.03, titled Infection Control Committee/Function, effective date 9/4/12, and provided by S6RN/IC/QA (Registered Nurse/ Infection Control/Quality Assurance) as current, revealed, in part, the following:
"It shall be the policy of this Hospital that the Infection Control Program be operated under the auspices of an Infection Control Committee/Function with representation from the Medical and Hospital Staff...The Infection Control Program is a comprehensive hospital wide program in which all hospital departments and disciplines shall be involved.
Procedure:
A. The Infection Control Committee shall determine all hospital policy related to infection control and shall provide for productive and effective implementation of that policy. The Infection Control Manual has been prepared by the Infection Control Committee to be used as a guideline in the prevention and control of infections. It is the official policy of the hospital to be followed the Medical and Hospital Staff...
B. The membership of the Infection Control Committee shall be established annually...
D. The Infection Control Committee shall meet at least quarterly and shall be responsible for:
1. Establishing infection control policies and procedures in light of the newest information and current practice.
2. Implementing and continually reviewing and evaluating infection control policies and procedures for each department within the hospital.
3. Establishing techniques for surveillance, investigation, control and prevention of hospital acquired infections for the following purposes:...b. to provide a basis of evaluation of new control measures or policies, c. to provide the patient and personnel with all possible protection from the development of nosocomial epidemics...8. monitoring all findings from any patient care quality assessment activities that relate to infection control, 9. Consultation regarding the purchased of equipment and supplies used for sterilization, disinfection, and decontamination purposes, 10. Periodically reviewing cleaning procedures, agents, and schedules in use throughout the hospital, and consultation regarding any major change in cleaning products or techniques...
15. Establishing and revising, as necessary, hospital isolation policies and procedures...
17. Taking appropriate action to correct infection control problems identified through surveillance, monitoring, or special studies.
20. Interacting and communicating with the Medical Staff Executive Committee, Administration, Nursing, and the Utilization Review Committee.


1) Appointment of Infection Control Officers not qualified through ongoing education, experience, or certification to oversee the infection control program:
Review of the personnel files of S2DON (Director of Nursing) , S3ADON (Assistant Director of Nursing, S6RN/IC/QA (Registered Nurse/Infection Control/Quality Assurance), S46RN/WC (Registered Nurse, Wound Care), and S39RN (Prior Infection Control Coordinator until 7/14) revealed no training, education, experience, or certifications that would qualify them to develop and implement an infection control program.
An interview was conducted with S6RN/IC/QA on 10/29/14 at 9:05 a.m. When questioned about his experience and training for being the hospital's Infection Control nurse, he reported he had no formal training or experience in infection control.

In an interview on 10/29/14 at 3:15 p.m. S2DON verified that neither S3ADON, S6RN/IC/QA, S39RN, nor himself had specialized training, education or experience in infection control program coordination and implementation. S2DON and S6RN/IC/QA confirmed that no training education for S6RN/IC/QA had been scheduled as of the time of the interview.


2) Failure to implement isolation precautions:
On 10/18/14 at 10:00 a.m., an observation was made of Patient #26 at the off-site campus. The patient was observed to have isolation supplies attached to the door with a sign indicating "Droplet Isolation." The patient was observed to be on a ventilator. S3ADON (Assistant Director of Nursing) was present for the observation and stated the patient was unresponsive. When asked why the patient was in isolation, S3ADON stated she did not know. S21LPN assigned to the patient stated the organism was a long name she could not pronounce. S21LPN then provided a sputum culture report dated 10/17/14 that revealed the patient had Stenotrophomonas.
At 10:05 a.m., another observation of Patient #26 revealed S3ADON and S11CRT/Lead were at the patient's bedside. S3ADON and S11CRT/Lead were observed to have isolation gowns on and gloves, but neither had a mask on. The isolation supplies attached to the door of the room now contained signage indicating the patient was on contact isolation. S3ADON was asked why the patient was on contact isolation if the organism was in the sputum. S3ADON stated the patient had an endotracheal tube and was on the ventilator and, "It is a closed system."

Review of the medical record for Patient #26 revealed the patient was a 69 year old male admitted to the off-site campus on 10/14/14 with diagnoses of Respiratory Failure requiring Ventilator, Pneumonia, Infectious Pneumonitis, Dementia, PEG Tube, and Uncontrolled Seizures. Review of the physician's admission orders revealed, "Contact Isolation Precautions." Further review of the physician's orders revealed on 10/17/14, Droplet Precautions were ordered.

In an interview on 10/28/14 at 1:05 p.m., S21LPN verified she was assigned to Patient #26. S21LPN stated the patient was on contact precautions when he was admitted, but droplet precautions were ordered on 10/17/14 when the final culture report came back. S21LPN stated respiratory therapy told her the patient should be on contact precautions because the ventilator was a closed system. S21LPN was unable to explain why or who changed the isolation precaution signage on the patient's door this morning. S20RN (Charge Nurse) who was present for the interview was unable to explain which precautions the patient should be on or why the isolation signage was changed.

In an interview on 10/28/14 at 2:45 p.m., S3ADON stated she changed the isolation signage from droplet isolation to contact precautions after she asked S11CRT/Lead what type of isolation the patient should be on. S3ADON stated S11CRT/Lead told her the patient was on contact precautions and respiratory had asked the Infection Control Nurse (S6RN/IC/QA) and said contact precautions. S3ADON stated she had reviewed the patient's medical record and found that the physician had ordered droplet precautions and she should not have changed the signage. The hospital's policy for droplet precautions was requested for review.

On 10/28/14 at 4:00 p.m., S3ADON provided two policies for review. Review of the policy titled, Standard Precautions, policy number III.R.18.07 revealed in part the following: 6. During aerosol-generating procedures (e.g., bronchoscopy, suctioning of the respiratory tract [if not using in-line suction catheters], endotracheal intubation) in patients who are not suspected of being infected with an agent for which respiratory protection is otherwise recommended (e.g., M. tuberculosis, SARS or hemorrhagic fever viruses), wear one of the following: a. face shield that fully covers the front and sides of the face, a mask with attached shield, or b. a mask and goggles (in addition to gloves and gown).
Review of the policy titled Guidelines for Isolation of Specific Conditions/Diseases revealed no documented evidence the procedure for Droplet or Contact isolation.


In an interview on 10/29/14 at 10:00 a.m., S2DON (Director of Nursing) stated the hospital based their isolation policy on OSHA (Occupational Safety and Health Administration) and CDC (Centers for Disease Control) guidelines. S6RN/IC/QA (Infection Control/Quality Assurance) was asked if he had provided guidance to the staff regarding contact/droplet precautions for patients on ventilators with in-line suction. S6RN/IC/QA stated he had told the staff if the physician ordered droplet precautions they should consult the physician. S6RN/IC/QA stated if droplet precautions were ordered droplet precautions should have been done. S2DON stated the presence of in-line suction should not make a difference in providing droplet precautions.

An observation 10/28/14 at 1:20 p.m. on patient care unit of offsite location revealed S40CNA exiting Patient #25's room wearing a yellow isolation gown and gloves. S40CNA reached into a clean, covered linen cart, then returned to Patient #25's room and shut the door. Further observation revealed PPE (Personal Protection Equipment: gowns, gloves, masks, head coverings, shoe coverings) holder hanging on the patient room door with a "Contact Isolation Precaution" sign on the PPE holder.
An observation 10/28/14 at 1:30 p.m. revealed S40CNA and S22CNA exiting Patient #25's room. S40CNA had removed her gown and gloves; S22CNA, still gowned and gloved exited carrying soiled linen, uncovered down to the end of the hall, where she unlocked, via a keypad, a soiled storage room while still wearing the gloves used in Patient #25's room. In an interview at the time of the observation S40CNA verified that she contaminated the clean linen when she reached in and touched it and touched contents of the linen cart with a contaminated glove while wearing a gown worn while changing an incontinent patient on contact isolation precautions. S40CNA verified that she carried soiled linen, used by a patient on isolation, uncovered through the hallway and contaminated the keypad and door handle to the soiled linen room. S40CNA reported that she should have had a covered linen container outside of Patient #25's door to transport the linen. The CNA further reported that the correct procedure was to transport soiled linen in a covered container, and to remove PPE before exiting a patient's room and perform hand hygiene as soon as exiting before touching anything else.

In an interview 10/28/14 at 2:55 p.m. S3ADON confirmed that soiled linens from any patient should not be transported uncovered out of a patient's room. S3ADON further verified it was the hospital's policy to remove PPE used in a patient's room before exiting the room, and to perform hand hygiene upon exit, before touching anything else. S3ADON agreed that the actions of S40CNA and S22CNA contaminated the clean linen cart and the keypad and door of the soiled linen room.


3) Failure to develop and implement policies and procedures relevant to construction, renovation, maintenance, demolition, and repair:
An observation 10/27/14 at 9:45 a.m. on entrance to the hospital revealed newly constructed sheetrock partitioned walls in the physical therapy room, enclosing space into 2 storage rooms, a conference room, and a therapy office. The walled partitions were noted to not go all the way to the ceiling. Draped between the ceiling and the top of the new partitioned walls were 2 canvas tarps, that attached at one point, each on the ceiling, but then draped over a small part of the top of one of the partitioned walls. The space between the 4 newly created spaces (and the therapy area) and the ceiling were open to each other. A 12 foot ladder was noted to be propped against one wall. Further observation into one of the storage spaces revealed respiratory equipment and supplies and nursing supplies. A thick, but fine white powdery dust covered a portable double suction machine. A fine powdered dust covered the rest of supplies and equipment. A thin, clear plastic bag (the size of an average leaf bag) was filled with a yellow material that resembled insulation used in walls. The floor in the patient therapy room and the conference room had a fine layer of white dust on it. Further observation in the therapy gym revealed a fine powdery dust covering the legs of the UPE (upper extremity) therapy equipment.
An interview was conducted with S14OT/Lead (Lead Occupational Therapist) on 10/27/14 at 9:45 a.m.
In an interview 10/27/14 at 9:45 a.m. S14LeadTheapist verified the above findings. S14LeadTheapist reported that construction had started last week sometime. She reported that there were no other barriers to contain the construction dust other than what was presently up. She reported she wiped the equipment off after patient use and at the end of the day. However, since the hospital has been doing construction in the gym, it had been a constant battle trying to remove the dust.

In an interview 10/28/14 at 9:30 a.m. S11CRT/Lead reported that she was not aware that insulation was stored in the same room as respiratory and nursing supplies on the main campus. S11CRT/Lead reported she had gone to the main campus last week and wiped down equipment in storage as nothing had been covered during construction and everything was covered in dust from construction.

In an interview 10/27/14 at 10:40 a.m. S1ADM (Administrator) reported that he would have to refer surveyors to the Maintenance Director for any information related to the construction being done, including any policies or procedures the hospital may have in place.

In an interview 10/27/14 at 11:20 a.m. S16MainDir (Maintenance Director) reported that the hospital did not have any policy and procedure, regulations, or guidelines for new construction, other than a policy that addressed fire prevention or life safety measures. S16MainDir further reported that the construction did not alter the fire safety system. When asked for any documentation related to the construction, S16MainDir reported that the only documentation he could provide would be floor plans, and that the work was being done in-house, as opposed to an outside contractor. When asked if any process to contain the construction dust and debris had been put into place, he replied that the door from the therapy room to the rest of the hospital was closed. After verifying that a bag of wall insulation was stored in the storage room with patient equipment and supplies, S16MainDir indicated that this was acceptable as long as the bag was closed.

In an interview 10/27/14 at 1:30 p.m. with S2DON verified a large bag of insulation was stored in the respiratory and nursing supply/equipment storage area just off the therapy gym with the construction. He further verified the dust covering equipment, supplies,and the floors. S2DON agreed that building/construction insulation should not be store with patient equipment and supplies. S2DON reported the hospital had not conducted an infection control risk assessment to define the scope of the project and need for barrier measures before the construction was begun, nor did the hospital have policies and procedures in place related to construction and infection control. S2DON reported that the hospital did not have an Infection Control Committee.



4) Failure to ensure Hand Hygiene practices were correctly and consistently implemented:
Review of hospital policy #III.R.18.02, titled Hand Hygiene, effective date 9/4/12, revision date 3/5/13, and provided by S2DON as current, revealed the following, in part:
Procedure:... If hands are not visible soiled, an alcohol-based hand rub may be used to decontaminate hands... C. 3. Decontaminate hands at the following times: a. Upon reporting to work, b. Before gloving, c. After glove removal, d. Before and after each patient contact, e. After handling contaminated objects, f. After contact with inanimate environmental sources likely to be contaminated, g. Before handling medication, h. Before eating, i. After using the restroom, j. When leaving the facility, k. When hands are visibly soiled...
F. Gloves: 1. Gloves should be used as an adjunct, not a substitute for hand hygiene. 2. Gloves should be changed,and hand hygiene performed after using gloves for contaminated activities 3. Gloves should be changed when caring for a single patient when moving from one procedure to another. 4. Hands should be washed when the integrity of the glove is in doubt, and between patients...G. This policy applies to all staff. H. If contact with spores (i.e., C. difficile) is anticipated, hand should be washed with antimicrobial or regular soap and water. Do not use alcohol, chlorhexidines, iodophore, etc, which have poor activity against spores.

On 10/27/14 at 10:30 a.m., an observation was made of Patient #6's room. The door of the patient's room was observed to have isolation supplies with a sign indicating the patient was on contact isolation. S8RD (Registered Dietician) was observed to put on an isolation gown and gloves and enter the patient's room. At 10:40 a.m. S8RD was observed to remove the isolation gown and gloves and leave the patient's room. After exiting the patient's room, S8RD was observed to place both her hands in her jacket pockets and proceed to the nurse's station. S8RD did not wash her hands or sanitize her hands after removing the gloves in the patient's room. S8RD confirmed she did not wash or sanitize her hands after removing the gloves and before putting her hands in her pocket.

An observation 10/28/14 at 1:20 p.m. on patient care unit of offsite location revealed S40CNA exiting Patient #25's room wearing a yellow isolation gown and gloves. S40CNA reached into a clean, covered linen cart, then returned to Patient #25's room and shut the door. Further observation revealed PPE (Personal Protection Equipment: gowns, gloves, masks, head coverings, shoe coverings) holder hanging on the patient room door with a "Contact Isolation Precaution" sign on the PPE holder.
An observation 10/28/14 at 1:30 p.m. revealed S40CNA and S22CNA exiting Patient #25's room. S40CNA had removed her gown and gloves; S22CNA, still gowned and gloved exited carrying soiled linen, uncovered down to the end of the hall, where she unlocked, via a keypad, a soiled storage room while still wearing the gloves used in Patient #25's room. In an interview at the time of the observation S40CNA verified that she contaminated the clean linen by reaching in and touch it and it's contents with a contaminated glove while wearing a gown worn changing an incontinent patient on contact isolation precautions. S40CNA verified that she carried soiled linen, used by a patient on isolation, uncovered through the hallway and contaminated the keypad and door handle to the soiled linen room. S40CNA reported that she should have had a covered linen container outside of Patient #25's door. The CNA further reported that the correct procedure was to transport soiled linen in a covered container, and to remove PPE before exiting a patient's room and perform hand hygiene as soon as exiting before touching anything else.

In an interview 10/28/14 at 2:55 p.m. S3ADON confirmed that soiled linens from any patient should not be transported uncovered out of a patient's room. S3ADON further verified it was the hospital's policy to remove PPE used in a patient's room before exiting the room, and to perform hand hygiene upon exit, before touching anything else. S3ADON agreed that the actions of S40CNA and S22CNA contaminated the clean linen cart and the keypad and door of the soiled linen room.

On 10/28/14 at 1:45 p.m. S20RN was observed in a transfusion administration. S20RN and S46LPN were observed to put on gloves and check the blood product. S20RN then removed her gloves and left the patient's room. S20RN was observed to retrieve an 3 ring
binder from the nurse's station and return to the patient's room. S20RN put on another pair of gloves and checked the patient's vital signs. S20RN then began documenting on the transfusion record. S20RN then checked the patient's temperature and started the transfusion. S20RN then removed her gloves and returned to documenting on the transfusion form. S20RN did not wash or sanitize her hands after removing her gloves. S20RN confirmed she did not wash her hands or use a hand sanitizer after removing her gloves.


26351

Based on observations, record review and interviews, the hospital failed to ensure the infection control officers developed an effective system that included identification, reporting, investigation, and controlling of infections and communicable diseases of patients and personnel, as evidenced by 1) failure to implement correct isolation precautions; 2) failure to maintain a sanitary environment; and 3) failure to have a policy and procedure in place to disinfect semi-critical instruments. Findings:

1) Failure to implement isolation precautions:
On 10/18/14 at 10:00 a.m., an observation was made of Patient #26 at the off-site campus. The patient was observed to have isolation supplies attached to the door with a sign indicating "Droplet Isolation." The patient was observed to be on a ventilator. S3ADON was present for the observation and stated the patient was unresponsive. When asked why the patient was in isolation, S3ADON stated she did not know. S21LPN assigned to the patient stated the organism was a long name she could not pronounce. S21LPN then provided a sputum culture report dated 10/17/14 that revealed the patient had Stenotrophomonas.
At 10:05 a.m., another observation of Patient #26 revealed S3ADON and S11CRT/Lead were at the patient's bedside. S3ADON and S11CRT/Lead were observed to have isolation gowns on and gloves, but neither had a mask on. The isolation supplies attached to the door of the room now contained signage indicating the patient was on contact isolation. S3ADON was asked why the patient was on contact isolation if the organism was in the sputum. S3ADON stated the patient had an endotracheal tube and was on the ventilator and, "It is a closed system."

Review of the medical record for Patient #26 revealed the patient was a 69 year old male admitted to the off-site campus on 10/14/14 with diagnoses of Respiratory Failure requiring Ventilator, Pneumonia, Infectious Pneumonitis, Dementia, PEG Tube, and Uncontrolled Seizures. Review of the physician's admission orders revealed, "Contact Isolation Precautions." Further review of the physician's orders revealed on 10/17/14, Droplet Precautions were ordered.

In an interview on 10/28/14 at 1:05 p.m., S21LPN verified she was assigned to Patient #26 today. S21LPN stated the patient was on contact precautions when he was admitted, but droplet precautions were ordered on 10/17/14 when the final culture report came back. S21LPN stated respiratory therapy told her the patient should be on contact precautions because the ventilator was a closed system. S21LPN was unable to explain why or who changed the isolation precaution signage on the patient's door this morning. S20RN (Charge Nurse) who was present for the interview was unable to explain which precautions the patient should be on or why the isolation signage was changed.

In an interview on 10/28/14 at 2:45 p.m., S3ADON stated she changed the isolation signage from droplet isolation to contact precautions after she asked S11CRT/Lead what type of isolation the patient should be on. S3ADON stated S11CRT/Lead told her the patient was on contact precautions and respiratory had asked the Infection Control Nurse (S6RN/IC/QA) and said contact precautions. S3ADON stated she had reviewed the patient's medical record and found that the physician had ordered droplet precautions and she should not have changed the signage. The hospital's policy for droplet precautions was requested for review.

On 10/28/14 at 4:00 p.m., S3ADON provided two policies for review. Review of the policy titled, Standard Precautions, policy number III.R.18.07 revealed in part the following: 6. During aerosol-generating procedures (e.g., bronchoscopy, suctioning of the respiratory tract [if not using in-line suction catheters], endotracheal intubation) in patients who are not suspected of being infected with an agent for which respiratory protection is otherwise recommended (e.g., M. tuberculosis, SARS or hemorrhagic fever viruses), wear one of the following: a. face shield that fully covers the front and sides of the face, a mask with attached shield, or b. a mask and goggles (in addition to gloves and gown).
Review of the policy titled Guidelines for Isolation of Specific Conditions/Diseases revealed no documented evidence the procedure for Droplet or Contact isolation.

In an interview on 10/29/14 at 10:00 a.m., S2DON stated the hospital based their isolation policy on OSHA (Occupational Safety and Health Administration) and CDC (Centers for Disease Control) guidelines. S6RN/IC/QA (Infection Control/Quality Assurance) was asked if he had provided guidance to the staff regarding contact/droplet precautions for patients on ventilators with in-line suction. S6RN/IC/QA stated he had told the staff if the physician ordered droplet precautions they should consult the physician. S6RN/IC/QA stated if droplet precautions were ordered droplet precautions should have been done. S2DON stated the presence of in-line suction should not make a difference in providing droplet precautions.

On 10/27/14 at 10:30 a.m., an observation was made of Patient #6's room. The door of the patient's room was observed to have isolation supplies with a sign indicating the patient was on contact isolation. S8RD (Registered Dietician) was observed to put on an isolation gown and gloves and enter the patient's room. At 10:40 a.m. S8RD was observed to remove the isolation gown and gloves and leave the patient's room. After exiting the patient's room, S8RD was observed to place both her hands in her jacket pockets and proceed to the nurse's station. S8RD did not wash her hands or sanitize her hands after removing the gloves in the patient's room. S8RD confirmed she did not wash or sanitize her hands after removing the gloves and before putting her hands in her pocket.

On 10/28/14 at 1:45 p.m. S20RN was observed in a transfusion administration provided to Patient #6. S20RN and S46LPN were observed to put on gloves and check the blood product. S20RN then removed her gloves and left the patient's room. S20RN was observed to retrieve an 3 ring binder from the nurse's station and return to the patient's room. S20RN put on another pair of gloves and checked the patient's vital signs. S20RN then began documenting on the transfusion record. S20RN then checked the patient's temperature and started the transfusion. S20RN then removed her gloves and returned to documenting on the transfusion form. S20RN did not wash or sanitize her hands after removing her gloves. S20RN confirmed she did not wash her hands or use a hand sanitizer after removing her gloves.


2) Failure to maintain a sanitary environment:
On 10/27/14 at 11:20 a.m., an observation was made of the crash cart for the main campus with the Charge Nurse (S18RN). S18RN stated the Charge Nurse was responsible for checking the crash carts. An accumulation of dust was noted on the defibrillator. A strip of adhesive tape was noted on the top edge of the cart. Partially removed labels were noted on each drawer of the cart. Multiple areas of missing paint were observed on drawer 5, leaving a rough, metal surface exposed. S18RN confirmed the presence of the dust accumulation on the defibrillator. S18RN confirmed the missing paint, label residue, and tape adhered to the cart did not provide a smooth, wipeable surface for disinfection.

On 10/28/14 at 9:40 a.m., an observation was made of the crash cart for the off-site campus with S3ADON (Assistant Director of Nursing). An accumulation of dust was observed on the defibrillator, the suction machine, and the top of the cart. An accumulation of dust was also noted on the ledge around the base of the cart. Adhesive label residue was noted on the drawers of the cart. S3ADON confirmed the presence of the dust accumulation on the defibrillator, suction machine, and on the cart. S3ADON confirmed the label residue on the drawers did not provide a smooth, wipeable surface for disinfection.

An observation was made on 10/27/14 at 10:00 a.m. in the patients' rooms of unpainted bare wooden shelves hanging on the walls, which included one shelf for each bed.
An interview was conducted with S30HkSup (Housekeeping Supervisor) on 10/27/14 at 10:45 a.m. He reported the bare wooden shelves had been hanging in patients' rooms for about 2 years. S30HkSup further reported, when questioned, if bare wood could be disinfected, and he reported bare wood could be disinfected.
An observation was made on 10/27/14 at 9:30 a.m. of an empty chart rack in the hallway by the therapy gym. The chart rack surfaces contained dried brown substances, a red substance, old adhesive tape, and an unknown spilled brown liquid. The observation of the substances contained on the chart rack surfaces was confirmed by S44LPN (Licensed Practical Nurse).
An observation was made on 10/27/14 at 11:00 a.m. of a storage area in the hallway with office supplies, an uncovered clean linen cart, a blood pressure machine, EKG (electrocardiogram) machines, and 2 box fans. The clean linen cart, which contained clean linen, was not covered. The 2 box fans had dust on them, an EKG machine had used EKG pads on the machine, and most of the equipment was not covered.
An interview was conducted with S2DON (Director of Nursing) on 10/27/14 at 11:00 a.m. S2DON confirmed the equipment stored in the supply room should be clean and covered with a plastic bag/covering. He further confirmed the equipment was not clean and was not covered, and the clean linen cart was not covered and should have been covered.
An observation made 10/27/14 at 11:40 a.m. with S45CNA (Certified Nursing Assistant) revealed the following: Patient shower room at the main campus had equipment stored in two of 3 shower areas. One area was large to accommodate a shower bed. In this large shower area were stored 1 shower bed and 4 bedside commodes. S45CNA reported she could not be sure if any of the equipment was clean and disinfected by looking at it. In a single shower area was 1 shower chair. S45CNA reported that there was no process for identifying whether the shower chair was clean and disinfected or not. In the other single shower stall, a light brown, pinkish , wet substances was noted in the back left corner of the shower, and on the lower wall tile grout. S45CNA obtained a paper towel, and wiped some of the substance away, but reported that she was unable to identify the substance. 3 used EKG leads were stuck on the arm of a bedside commode sitting in the middle of the room outside of the shower stalls. An opened and used looking Band-Aid was stuck to the wall next to a garbage can. The one sink in the bathroom was observed to be in the shower area for a shower bed. In the sink were two items identified by S45CNA as a potty chair cover and a disposable wash basin. S45CNA verified that the sink was not assessable due to the contents in the sink and the shower bed blocking access. S45CNA reported that the last patient shower that had taken place in the shower room was yesterday.
On 10/28/14 at 9:20 a.m., an observation was made at the nurse's station on the off-site campus. S3ADON was present for the observation. 1 large garbage can was observed parked on the side of the nurse's station. The can had no lid and was over flowing with plastic bags of trash. Also noted next to the can were 2 plastic bags of trash placed on the floor next to the garbage can. S3ADON confirmed the plastic garbage bags were placed on the floor and they should not have been. S3ADON then asked S31Hk (Housekeeping) to remove the bags of trash.

On 10/28/14 at 9:25 a.m., an observation was made in patient room 203 with S3ADON. Sticky tape residue was noted on the siderails of both beds in the room. S3ADON confirmed the residue and stated it was probably from electrodes applied to the nurse call button to assist patients to tell where the call button was. S3ADON confirmed the sticky residue did not provide a smooth wipeable surface for disinfection. The A bed in room 203 was also observed to have a 1 inch by 3 inch "L" shaped tear in the covering of the bed mattress. S3ADON confirmed the mattress covering was torn and the bed could not be disinfected.

On 10/28/14 at 9:30 a.m., an observation was made of the Soiled Utility room at the off-site campus. S3ADON was present for the observation. The Soiled Utility room was observed to contain biohazard waste, bags of garbage, and soiled patient care equipment. Also stored in the cabinets and on the counter in the room was multiple rolls of toilet paper, rolls of paper towels, and unused biohazard bags and clear plastic bags. S3ADON confirmed the clean supplies were stored in the Soiled Utility room and they should not have been.

An observation was made 10/28/14 at 9:40 a.m. of S31Hk cleaning a patient's room. During the observation S31Hk was asked if the disinfectant she was using had to sit any specific length of time before wiping the item. S31Hk reported that you just had to spray the disinfectant on for 2 or 3 minutes and them wipe it off. After reviewing the label on the bottle of disinfectant, S31Hk verified the directions were to let the disinfectant sit for 10 minutes before wiping off.


3) Failure to have a policy and procedure in place to disinfect semi-critical instruments:
On 10/27/14 at 11:40 a.m., an observation was made of emergency respiratory supplies with S12CRT (Certified Respiratory Therapist) at the main campus. A cardboard box was noted in the respiratory box and was opened. Inside the box was 2 laryngoscope handles and multiple laryngoscope blades. S12CRT verified the handles and blades were all stored in the cardboard box. When asked how the laryngoscope blades and handles were disinfected, she stated she did not know. S6RN/IC/QA who was present for the observation also stated he did not know how the laryngoscope blades and handles were disinfected after use. S6RN/IC/QA stated he would look for the hospital's policy on disinfecting the blades and handles.

On 10/28/14 at 9:25 a.m., an observation was made of the emergency respiratory supplies with S11CRT/Lead at the off-site campus. S11CRT/Lead stated she was the Director of Respiratory for both campuses. Laryngoscope handles and blades were observed to be contained in individual zip lock bags. When asked how the blades and handles were disinfected, S11CRT/Lead stated the laryngoscope blades are soaked in bleach or Cidex and the handles are wiped with Sani Wipes. S11CRT/Lead stated the hospital did not have a specific policy for disinfecting the laryngoscope blades and handles and provided the policy titled, "Cleaning of Non-Critical, Reusable Patient Care Equipment" as the current policy.

Review of the hospital policy titled, Cleaning of Non-Critical, Reusable Patient Care Equipment" revealed no provisions for disinfecting laryngoscope blades and handles. No policy relevant to cleaning and disinfecting Semi-Critical equipment was provided.

Review of the CDC (Centers for Disease Control) Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 revealed laryngoscope blades are considered Semicritical and minimally require high-level disinfection.

In an interview 10/29/14 at 9:30 a.m. S11CRT/Lead (Certified Respiratory Technician) confirmed that she was the supervisor of the Respiratory Department. S11CRT/Lead reported the hospital did not have a policy and procedure for disinfection of laryngoscope blades after use or contamination. She further reported she would clean them with Clorox or Cidex as that is how she had always cleaned them in previous places of employment. She reported that other staff would know how to clean them because she would tell them if they asked.


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Based on medical record review and staff interviews, the hospital failed to ensure radiology reports were signed/authenticated by the practitioner who performed the radiology service for 3 (#4, #26, #27) of 4 (#4, #26, #27, #29) sampled records reviewed for radiology services at the main and off-site campuses. Findings:

Review of the Medical Staff Rules and Regulations presented as current by S1ADM (Administrator) revealed in part the following: Section 5 Medical Record: 5.1.2 All medical record entries must be legible, complete, dated, timed and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided consistent with hospital policy and procedure.

Patient #4
Review of the medical record for Patient #4 revealed a chest x-ray was done on 10/06/14 and 10/14/14 by Company A. Review of the Final Radiology Reports dated 10/06/14 and 10/14/14 revealed no documented evidence of the signature of the Radiologist. The forms revealed, "Electronically signed by:", but there was no electronic signature. Further review of the reports revealed both the reports were 1 of 1 pages.

In an interview on 10/27/14 at 3:20 p.m., S2DON (Director of Nursing) reviewed the medical record for Patient #4 and verified the Radiology Reports dated 10/06/14 and 10/14/14 were not signed by the radiologist. S2DON was observed to call Company A regarding the radiologist signature on the x-ray reports. S2DON stated the director at Company A told him sometimes the signature is on the second page and maybe it was faxed but not attached to first page. S2DON also indicated the only monitoring of the services provided by Company A was the turnaround time of routine and stat tests.


Patient #26
Review of the medical record for Patient #26 revealed a chest x-ray was done on 10/15/14 by Company A. Review of the Final Radiology Report dated 10/15/14 revealed no documented evidence of the signature of the Radiologist. The form revealed, "Electronically signed by:", but there was no electronic signature. Further review of the report revealed the report was 1 of 1 pages.

In an interview on 10/28/14 at 2:45 p.m. S3ADON (Assistant Director of Nursing) reviewed the medical record for Patient #26 and verified the chest x-ray report dated 10/15/14 was not signed by the radiologist.


Patient #27
Review of the medical record for Patient #27 revealed a chest x-ray was done on 10/15/14 and 10/20/14 by Company A. Review of the Final Radiology Reports dated 10/15/14 and 10/20/14 revealed no documented evidence of the signature of the Radiologist. The form revealed, "Electronically signed by:", but there was no electronic signature. Further review of the report revealed the report was 1 of 1 pages.

In an interview on 10/28/14 at 5:00 p.m. S3ADON reviewed the medical record for Patient #27 and verified the chest x-ray reports dated 10/15/14 and 10/20/14 were not signed by the radiologist.

In an interview on 10/29/14 at 1:50 p.m., S2DON stated the only quality indicators monitored for radiology services were the turnaround times for routine and stat testing.

Based on observations, record review, and staff interview, the Chief Executive Officer, Medical Staff and Director of Nursing (DON) failed to ensure the QAPI program addressed infection control problems and implemented successful corrective action plans as evidenced by:
1) failing to conduct infection control surveillance of the hospital environment, collect data, track and trend and develop corrective actions plans resulting in observed infection control breeches at both campuses of the hospital;
2) failing to implement successful corrective action plan to address breeches in hand hygiene at both campuses of the hospital;

Findings:

1) Failing to conduct infection control surveillance of the hospital environment, collect data, track and trend and develop corrective action plan resulting in observed infection control breeches at both campuses of the hospital environment:

Review of An Infection Control Surveillance Audit Form , provided by S2DON revealed, in part, blank forms that included an Infection Control Surveillance Audit Form. A place for the reviewer's name and month in review were provided. The Indicator was " Compliance with Hospital wide infection control practices, policies, and procedures." Instructions were: "Ongoing observations by ICN (Infection Control Nurse) and assigned Department Managers of the environment and interviews of staff. Minimum rounds 2x/week. May be in coordination with EOC (Environment of Care) rounds," Information for each entry was to be documented with date/time, areas(s) surveyed, Information of Staff initials, time of date, etc, and marked under Yes, No, or N/A columns, as well as the total number compliant and the total number of observations. The data points, or observations noted were:
-Visitors compliant with isolation precautions as posted including wearing of PPD (Personal Protective Equipment) and handwashing.
-Staff compliant with isolation precautions as posted including proper use of PPE, handling of linen and cleaning of medical equipment and supplies.
-Refrigerator temperature logs up to date without gaps or missing data. Reading outside range were reported and have action taken recorded.
-Clean and dirty supplies and equipment are kept separate. Clean and dirty areas visibly identified with appropriate signage.
-Sanitary environment is maintained free of dust, debris or potential contamination. Floor surfaces/furniture easily washable and clean.
-Isolation precaution signage is consistent with required precautions as result of cultures obtained.
-Isolation carts stocked with PPE and dedicated equipment per policy.
-Linen within room, and taken to and from isolation rooms properly handled and disposed of by caregivers.
-Patient family, visitors and staff demonstrated knowledge of the REASON for isolation
-Linen storage areas complaint with hospital policy, infection control practices and regulatory requirements.
-Patients infected or colonized with a multi-resistant organism and families received education about HAI (Healthcare Acquired Infections) prevention strategies.
-Hand Sanitizers available outside each room with sufficient product...
-Supply rooms neat and tidy. No boxes on the floor. Bottom shelves solid. 18" (inches) from sprinkler heads. No expired supplies.
-Nutrition room clean-refrigerator cleaned routinely. No expired food.
-Medical equipment "bagged and tagged"
Page 3 of 3 was blank and titled " Opportunities for Improvement. Be sure to date and time your notes."

Further review of Infection Control audit tools/forms provided by S2DON and S6RN/IC/QA revealed titled audit tools of Handwashing Observation Audit Form , Central Line Bundle (a group of evidence based interventions for patients with intravascular central catheters, that include hand hygiene, Maximal Barrier Precautions Upon Insertion, Chlorhexidine Skin Antisepsis, Optimal Catheter Site Selection, and Daily review of Line necessity with prompt removal of unnecessary lines)., Central Line Dressing Change, and CAUTI (Catheter Associated Urinary Tract Infection Event), and Environment of Care Rounds ( with Safety and Life Safety, Security, Equipment Management, Utilities, Hazardous Materials included).

In an interview 10/29/14 at 3:15 p.m., S2DON reported that after entering the data collected on the above surveillance and audit tools into an electronic program (Action Cue), the tools are disposed of and were not kept. S2DON further reported Performance Improvement reports from the Action Cue program showed percentages for each month,and compared the compliance percentage against other hospitals and benchmarks. S2DON, after reviewing Performance Improvement reports for Hand Hygiene Compliance with surveyors, agreed that one could not analyze the report for identification of problem areas, and therefore identify action plans to correct and monitor. Review of a Cleanliness of Facility Environment report revealed all "0" data for October 2013 through September 2014, verified by S2DON. S2DON stated the only monitoring done related to the cleanliness of the hospital environment was from the patient satisfaction surveys. S2DON verified no risk assessment or procedure had been developed or put into place regarding the present construction project in the Therapy gym. No raw data collected for infection control was provided.


2) Failing to implement successful corrective action plan to address breeches in hand hygiene at both campuses of the hospital:

Review of the QAPI records revealed hand hygiene was a performance measure of the infection control department and data was reported monthly by both campuses of the hospital. Review of the QAPI records revealed the hospital's benchmark was 85% compliance.
Review of the Hand Hygiene Compliance revealed the following for 2014:
Main Campus Off-Site Campus
Jan - 79% Jan - 86%
Feb - 80% Feb - 79%
Mar - 68% Mar - 75%
Apr - 83% Apr - 69%
May - 88% May - 71%
June - 96% June - 68%
July - 96% July - 77%
Aug - 90% Aug - 79%
Sept - 84% Sept - 82%

Review of the Action Cue report for Hand Hygiene Compliance revealed the only documented corrective action to addressed the staff non-compliance with hand hygiene was to educate and stress the importance of hand washing in staff meetings and install more sinks. There was no documented evidence of any further corrective actions to address hand hygiene.

In an interview on 10/29/14 from 1:25 p.m., S2DON confirmed he was the interim Quality Assurance co-coordinator until S6RN/IC/QA (Registered Nurse, Infection Control/Quality Assurance) completed orientation. After reviewing the Action Cue reports for Hand Hygiene Compliance for the last 12 months, S2DON stated he entered his documentation of hand hygiene surveillance onto the Action Cue system and then he destroyed the raw data. S2DON verified he had no documentation of any data collected related to hand hygiene. When asked what corrective actions had been done to address the failure to meet the identified benchmark of 85%, S2DON stated they educated and stressed to the staff the importance of hand washing and they had identified the need for additional sinks for handwashing. S2DON confirmed no new actions had been implemented to address the repeated lack of compliance with hand hygiene other than educating the staff. S2DON further stated no one person was responsible for overseeing QAPI. S2DON stated each department tracks their own QI and he did not know what they are tracking. When asked if he would be adding more infection control indicators, S2DON stated no, he, "Would like to", but it would have to be corporate wide and he could not add indicators in the Action Cue. S2DON stated AMG corporate chooses the quality indicators that the hospitals would track & trend.