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Based on document review and interview, the governing body failed to ensure that the quality assessment and performance improvement (QAPI) program evaluated all contracted services at the facility for 2 of 20 contracted services (instrument sterilization service and surgical services).

Findings:

1. The policy/procedure Improving Organizational Performance Plan (approved 1-13) indicated the following: "The governing board shall require review and evaluation of patient care activities to assess, preserve, and improve the overall quality, safety, and efficiency of patient care and services in the hospital...the leadership of the Hospital through the CEO with his/her senior management staff and QAPI committee...shall actively support the program by ...performing evaluations of all clinically contracted services..."

2. QAPI monitoring documentation failed to indicate the instrument sterilization service and the surgical services provided by agreement were being evaluated through the program.

3. In interview on 6-17-15 at 1320 hours, the director of quality management A3 confirmed the two contracted services were not being reviewed by the QAPI program.

Based on document review and interview, the governing body failed to ensure that the quality assessment and performance improvement (QAPI) program evaluated all departments and services at the facility for 2 of 20 contracted services (instrument sterilization service and surgical services).

Findings:

1. The policy/procedure Improving Organizational Performance Plan (approved 1-13) indicated the following: "The governing board shall require review and evaluation of patient care activities to assess, preserve, and improve the overall quality, safety, and efficiency of patient care and services in the hospital ...the leadership of the Hospital through the CEO with his/her senior management staff and QAPI committee...shall actively support the program by ...performing evaluations of all clinically contracted services ..."

2. QAPI monitoring documentation failed to indicate the instrument sterilization service and the surgery services provided by agreement were being evaluated through the program.

3. In interview on 6-17-15 at 1320 hours, the director of quality management A3 confirmed the two contracted services were not being reviewed by the QAPI program.

Based on document review and interview, the infection control officer failed to implement the facility policy related to completing an ICRA (infection control risk assessment) prior to performing new construction or renovation for one area observed. (Area behind the West nurses' station.)

Findings:
1. Review of the policy "Infection Prevention and Control Construction and Renovation Guidelines", policy number R.14.45, infection control plan and policies last approved 1/20/15, indicated:
a. Under "I. Policy", it reads: "Planning for facility renovation and construction projects at [facility] includes early consultation with Infection Control to ensure that the design of treatment areas and other structures will facilitate desired infection control practices, and dust and other microbial contamination is minimized during the work phases of construction/renovation projects."
b. Under "I. Policy:...1.", it reads: "...Preconstruction preventive measure: a. Infection Prevention & Control will be notified of plans for renovation...during the planning phases by the Director of Plant Operations. The Risk Assessment and Preventive Measures Checklist [See Attachment #1] will be completed by the Director of Plant Operations and a copy given to the Infection Prevention & Control department...".

2. At 11:30 AM on 6/15/15, while at the East unit nurses' station, it was observed that:
a. A plastic barrier was hanging floor to ceiling behind the West unit nurses' station with workers moving in and out of the plastic while performing some sort of construction activity.
b. The occupied patient rooms were across the hall from the plastic/construction area with approximately 4 feet between the plastic and one occupied room.
c. This activity was also observed on 6/16/15 and 6/17/15.

3. Interview with staff member #51, the infection practitioner, at 11:45 AM on 6/15/15, indicated:
a. The host hospital infection practitioner was queried for an ICRA, but stated that none was needed for the renovation being done by the host physical plant/operations department staff.
b. The host hospital employees are doing a renovation by building up the fire wall (the cutting of current dry wall, and putting up new dry wall, are included in the project).
c. This staff member failed to complete an ICRA for this renovation, as well as the host hospital failing to complete one.

Based on document review and interview, the infection control practitioner failed to implement facility policies related to annual fit testing for 9 of 12 employee files reviewed (Staff members #21, #22, #23, #25, #27, #28, #29, #30 and #31); failed to implement the TB (tuberculosis) policy related to two step testing for 2 of 5 employees hired in 2014 (#25 and #26); and failed to ensure proper techniques for the prevention of cross contamination in 1 of 1 central line dressing changes observed (nurse #61 with dressing change for pt. #4).

Findings:
1. Review of the policy "N95 Fit Test", policy number III.R.18.15, policies approved by the health profession council/professional practice committee on 1/20/15, indicated:
a. Under "I. Policy", it reads: "All clinical staff will be trained in proper use of N-95 particulate respirator. All clinical staff will have a documented fit test performed upon hire and annually...".

2. Review of the "TB Exposure Control Plan", policy number III.R.18.24, approved by the health profession council/professional practice committee, on 1/20/15, indicated:
a. On page 7 under section "9. Personal Respiratory Protection", it reads, in item "iii.": "Fit Testing: HCWs (health care workers) will be fit tested for an appropriate respirator that adequately fits the face of each individual being fit tested. HCWs will be fit tested on hire and annually...".
b. On page 4 under "7. Employee Screening", it reads: "A. All employees will participate in the TB Exposure control plan by screening via TB skin test...at the time of employment...C. Failure of an employee to complete the two-step testing within 2 weeks of hire will result in removal from the work schedule...E. A second TST (tuberculin skin test) is not needed if the health care worker (HCW) has a documented negative TST result any time during the previous 12 months...".

3. Review of employee files regarding fit testing indicated:
a. #21 was a LPN (licensed practical nurse) hired 4/3/13 with a fit test done 4/9/13, and none done since that time.
b. #22 was a LPN hired 8/26/13 with a fit test done 8/26/13, and none done since that time.
c. #23 was a RN (registered nurse) hired 5/1/12 with a fit test done 5/28, and none done since then. (The form had no year written down, only read 5/28).
d. #25 was a RN hired 3/4/14 with a fit test dated 3/4/14, and none since that time.
e. #27 was a RN hired 8/26/13 and a fit test done 8/26/13, with none done since that date.
f. #28 was a PCT (patient care tech) with a hire date of 9/30/13 and a fit test of the same date, with none done since.
g. #29 was a LPN hired 5/1/12 and a fit test of 5/28/13, but none done in 2014 or 2015.
h. #30 was a LPN hired 5/13/15 with no fit test done at this time, or provided prior to exit.
i. #31 was a RN hired 5/5/14, with no fit test provided prior to exit.

4. Review of employee files regarding TB testing indicated:
a. #25 was a RN who started at the facility on 3/4/14 and had no documentation of having had a TB test.
b. #26 was a RN who started at the facility on 9/30/14 and had no documentation of having had a TB test.

5. At 1:17 PM on 6/16/15, interview with staff member #51, the infection preventionist, indicated fit tests are only being done at the time of hire, as it was not known that facility policy requires that an annual fit test needs to be performed.

6. At 2:20 PM on 6/16/15, interview with staff member #51, and #56, the director of human resources, indicated:
a. For RN #23, the year was most likely 2013.
b. Both RN #25 and #26 work at the host hospital who does not do annual TB testing as their risk assessment indicates they are a low risk for incidence of TB.
c. This facility failed to do even one TB test at the time of hire for RNs #25 and #26.
d. RNs #25 and #26 had no TB test within 12 months of hire at this facility and should have had two step TB tests performed.

7. In the company of staff member #51, the infection practitioner, at 11:55 AM on 6/16/15, RN (registered nurse) #61 was observed performing a sterile dressing change on the patient in room 8129, pt. #4, who was in contact precautions for C-Diff. It was observed, after the dressing change was performed, that RN #61 reached into their scrub pocket (under the protective gown and with sterile gloves on) to retrieve an ink pen for documenting on the dressing the date and time of dressing change. RN #61 reached back into their pocket for a different pen, and then reached in a third time to place the pen back in their scrub pocket, all while wearing gloves that had performed the dressing change on the isolation patient.

8. At 12:30 PM on 6/16/15, interview with staff member #51 indicated:
a. It was agreed that RN #61 broke technique by placing their contaminated gloved hand into their scrub pocket for a pen.
b. Staff RN #61 contaminated both their scrub attire and the pen they will continue to use the rest of the day, by breaking technique as stated in 7. above.

Based on document review and interview, the patient discharge planning evaluation lacked an assessment of the potential medical equipment and services needed upon discharge and the potential for self care and/or being cared for in the pre-hospitalization setting for 1 of 5 medical records (MR) reviewed (patient 22).

Findings:

1. The Long Term Acute Care (LTAC) facility policy/procedures titled Case Management Protocol (approved 11-12), and Case Management Documentation (approved 11-12) lacked a provision to evaluate the potential need upon discharge for medical equipment in use at the time of admission or to evaluate the possibility of the patient being cared for in the pre-hospitalization setting.

2. The MR for patient 22 indicated a complex hospitalization episode involving cardiac surgery with valve replacement and valve repair, new onset left parietal cerebral-vascular accident (stroke) with encephalopathy, respiratory failure with tracheostomy, and dysphagia with feeding tube (PEG) placement prior to the time of admission on 2-13-15 to the LTAC facility and indicated the patient was discharged from the LTAC facility on 4-13-15 to a skilled nursing facility (SNF) with ventilator support services. The initial discharge planning evaluation dated 2-16-15 failed to identify the potential need upon discharge for a ventilator or feeding pump in use at the time of admission or identify the potential need for SNF services at the time of discharge.

3. In interview on 6-17-15 at 1240 hours, the director of quality management A3 confirmed that the initial discharge planning assessment failed to identify and assess the potential need for medical equipment or likelihood of skilled nursing services needed by the patient at the time of discharge.

Based on document review and interview, the facility failed to ensure a list of home health agencies (HHAs) and/or skilled nursing facilities (SNFs) was presented when indicated and documented in the medical record (MR) for 3 of 5 MR reviewed (patient 22, 23, 25).

Findings:

1. The policy/procedure Referrals For Discharge Care/Placement (approved 11-12) indicated the following: "If the patient or family have not utilized an agency, a listing of choices will be given to them, for their decision." The policy/procedure failed to indicate a requirement to document in the MR that the agency (HHA) list of choices was provided or document in the MR when a list of SNFs was provided to a patient or patient's representative.

2. The MR for patient 22 failed to indicate a list of SNFs was provided to a patient or their representative on or before 3-16-15 when an entry indicated a referral request was sent to a SNF.

3. The MR for patient 23 failed to indicate a list of HHAs was provided to a patient or their representative on or before 3-03-15 when a discharge order entry indicated a HHA would provide equipment and/or supplies.

4. The MR for patient 25 failed to indicate a list of SNFs was provided to a patient or their representative on or before 2-09-15 when an entry indicated a referral follow-up was sent to a SNF and failed to indicate a list of HHAs was provided to a patient or their representative on or before 2-14-15 when a discharge order entry indicated a HHA would provide equipment and/or supplies.

5. In interview on 6-17-15 at 1440 hours, the director of quality management A3 confirmed that the MR documentation for patient's 22, 23, and 25 failed to indicate a list of HHAs or SNFs was provided to the patient or patient's representative.