HospitalInspections.org

Based on a review of the current Medical Staff By Laws, Rules and Regulations (as compared with the information available for review) regarding privileges granted to members of the medical staff and the actual practice of these same practitioners and verified by staff interview, the Medical Staff failed to follow the bylaws to clearly and completely list the specific privileges that reflected the practitioners actual practice and granted privileges to practitioners without evidence of demonstrated proficiency. This failed practice put all patients receiving services at the hospital at risk. The hospitals reported inpatient census was 44 on the day of entrance.

Findings include:

1. Under the Medical Staff Bylaws specified under Qualifications for ...Privileges, 2.3.4" Applicants shall demonstrate recent clinical performance within the last twenty-four months(24) with an active clinical practice in the area in which hospital privileges are sought adequate to meet current clinical competence criteria." A selected sample of six (6) current medical staff member credential files were reviewed. All six practitioners (Practitioners F, G, H, A, B, and C) were granted 'core' privileges for which there was a lack of demonstrated evidence of competency or proficiency present in their credential files.

2. Review of three (3) Active Medical Staff members: 1) an (F) Internal Medicine practitioner (someone who specializes in the management of organ related diseases); 2) a (G) Neurologist ( someone who manages conditions of the brain and spine) and 3) a (H) physiatrist (someone who treats injuries involving muscles and their recovery) were granted privileges for joint injections, burn care, and wound debridement (removing dead skin from an open wound). The files of all three practitioners ( Practitioners F, G and H) lacked evidence of competency to perform any of the above procedures.

Interview with the Director of Risk Management on 12-6-17 at 10:00 A.M. confirmed none of these practitioners had performed any of the procedures granted.

2. Under the category of Consulting Medical Staff qualifications specified under item 3.2.2 c. "Provide information requested for assessment of clinical competence, clinical privileges and other qualifications at the time of initial appointment and reappointment".
three (3) consulting physician files were selected for review. These were: 1) Practitioner A - a Pulmonologist (someone who treats conditions of the lungs); 2) Practitioner B - a Radiologist (someone who interprets patient xray images), and 3) Practitioner C - a Consulting Infectious Disease Specialist (someone who provides specialized knowledge on management of infections in patients).

All three (3) were granted core privileges to perform Abdominal paracentisis (draining fluid from the abdomen), Arthrocentesis(aspirate fluid from a joint), Burn care, injections of small and medium joints, wound debridement (removal of dead skin), Central Line Placement (a permanent intravenous line for medication administration) and Lumbar puncture (aspirating fluid from the spinal canal).
The files of all three of these physicians (Practitioners A, B and C) lacked evidence of proficiency for any of these procedures.

An interview with the Director of Risk Management on 12-6-17 at 10:00 A.M. confirmed none of the procedures had been performed by these practitioners and that Practitioner A primarily consulted on patients requiring mechanical ventilator management.
(A mechanical ventilator is a device that assists the air flow into the lungs of the patient ); Practitioner B interpreted radiologic images only and Practitioner C consulted only on patients with complex infectious conditions.

Based on record review, review of the facility policy and staff interview the facility failed to ensure that 1 of 30 sampled patients (Patient 23) had an updated History and Physical (H&P) report on the chart following a discharge and return following an emergency hospitalization in another acute facility (Hospital B) as per the facility policy. This has the potential to effect the continuity of care for any patients discharged for emergency hospitalization who returned to the facility.

Findings are:

A. Review of Patient 23's medical record (admission date of 11/27/17) revealed the patient returned from a 5 day hospital admission in (Hospital B) for the treatment of acute hypercapnic respiratory failure (an inadequate gas exchange of oxygen and carbon dioxide in the blood, hypercapnic is a build up of carbon dioxide and the decrease of oxygen leading to respiratory failure); acute heart failure (a condition where the heart cannot adequately pump blood to provide oxygen to body); and acute kidney injury (a condition where the kidneys suddenly stop filtering wastes from blood).

Patient 23's medical record revealed the patient had been admitted to this facility initially on 11/18/17 for IV antibiotics for 6 weeks following a T 8-9 discitis surgery (surgery to relieve imflammation of the thoracic spine at the level of 8-9) and osteomyelitis (infection of the bone) and was transferred on 11/22/17 to (Hospital B) for treatment of acute hypercapnic respiratory failure.

Review of Patient 23's medical record revealed a lack of a new H & P or mention of referring to previous H & P in the readmission 11/27/17 progress note. Review of the provider Progress Note dated 11/27/17 revealed, "Patient returns from unplanned discharged to (Hospital B) on 11/22 for acute hypercapnic respiratory failure and altered mental status. (Pt 23) was diagnosed with acute congestive heart failure leading to pulmonary edema (excess fluid in the lungs) and opioid overdose (a build up of opioid medication in the system causing respiratory difficulties and altered consciousness). (Pt 23) received lasix (medication to remove excess fluid from the body) an managed on BIPAP (a machine that assists the patient with breathing by delivering air at inhalation) by Pulmonary (lung doctor). Hospital course complicated by acute kidney injury associated with hyperkalemia (High potassium level in blood) for which renal ultrasound (ultrasound of kidney) showed no obstruction but did suggest chronic pathology." The provider progress note lacked information regarding initial admission diagnosis and lacked referral to the previous H&P from 11/22/17.

B. Review of the facility policy named "Healthcare Provider Documentation and Compliance Standards" with a review date of 7/25/16 revealed:
-The History and Physical Examination will be completed within 24 hours of admission by the Admitting Provider.
-If an History and Physical has been completed within 30 days prior to the current admission date and has been updated within 24 hours of the current admission to reflect the patient's current status and plan of care, it may be used in lieu of completing a new H&P.

C. Interview with the Administrator on 12/7/17 at 11:30 AM revealed that "It is the expectation of the facility that the provider either complete another History and Physical or complete a progress note that refers to the previous History and Physical and update on the current diagnosis and symptoms.

Based on observation, staff interview, and record review; the facility failed to ensure the glucometer (device to test blood sugars) and the glucometer's case was thoroughly disinfected when taking from patient room to patient room or to the nursing room for charging. Observation of blood sugar testing with the glucometer included Patients 31 and 9. This lack of thorough cleaning had the potential to spread infectious disease to all patients requiring blood sugar testing with a glucometer. The facility census at the time of entrance was 44.

Finding included:

A. Observation of Patient 31's blood sugar testing on 12/5/17 at 11:30 AM revealed:
-RN (Registered Nurse) J placed the glucometer case directly on the patient's bed, removed the glucometer and placed the glucometer directly on the patient.
-RN J tested the patient's blood sugar with the glucometer and placed the glucometer directly back into the case. RN J then picked up the glucometer out of the case and wiped the glucometer off with a Super San-cloth wipe and placed it back in the case.
-RN J picked the glucometer back up out of the case to compare the insulin order with the blood sugar and to double check the order with another nurse. RN J placed the glucometer on the computer work station and then wiped the glucometer off with a Super Sani-cloth and returned it to its case.
- RN J was observed wiping the top of the glucometer case before leaving the room. The bottom of the glucometer case was not disinfected. The glucometer case was placed on the computer work station and then placed on the work station outside the patient's room having the potential to spread infectious diseases.

Interview with RN J on 12/5/17 at 11:37 AM revealed that Patient 31 had blood sugar testing five times daily and the patient was not assigned a glucometer, so the patient had to use a glucometer that was used for multiple patients.

B. Observation of Patient 9's blood sugar testing on 12/6/17 at 11:35 AM revealed:
-RN K placed the glucometer case on the patient's over the bed table (on the tray pull out area).
-RN K kept the glucometer in the case during the blood sugar testing.
-RN K placed the glucometer case on the computer workstation and wiped the glucometer and top of the glucometer
case with a Super Sani-cloth. RN K did not wipe the bottom of the glucometer case before setting it on the computer work station having the potential to spread infectious diseases.

C. Interview with RN L revealed that the glucometers were disinfected after patient use along with the top and bottom of the case. The glucometers were used on different patients and then taken to the nursing area to be charged.

D. Review the facility's Blood Glucose (sugar) Monitoring policy dated 11/15/16 stated "7. Change gloves and disinfect glucometer machine with approved facility disinfecting wipes (like PDI super sani-cloth)."

E. Review of the manufacturer's cleaning instructions for the ACCU-CHECK Inform II (glucometer) box (case) and meter revealed:
-Place the accessory box on a level surface prior to cleaning.
-Squeeze an approved wipe (Clorox Germicidal Wipe or Super Sani-Cloth wipe) to remove excess solution and clean the case with the wiping away any visible soil. Use addition wipes as needed.
-Dry the accessory box surfaces thoroughly with a soft cloth or gauze after cleaning ensuring that no solution is seen anywhere on the accessory box.
-Use an approved product to disinfect the meter using either Clorox Germicidal wipes for one full minute or two full minutes if using Super Sani-Cloth wipes.

F. Interview with the Infection Control Prevention RN on 12/6/17 at 1:15 PM acknowledged that the above observations did not follow the facility's policy and procedures.

Based on facility respiratory department maintenance record review; staff interview and facility policy; the facility failed to ensure the Arterial Blood Gas Machine (EPOC Blood Analysis System- a point of care machine to measure the patients oxygen and chemistry in their blood effecting their respiratory status.) quality control was not completed in 1 of the last 12 months (November 2017) and the recording of the Respiratory Service work room's temperature and relative humidity log was only completed daily for 4 of the last 5 months (July, August, October and November). This has the potential to effect all patients requiring Arterial Blood Gases at the facility.

Findings are:

A. Review of the Monthly Quality Control checks log revealed that the Quality Control check was not completed in the month of November 2017.

An interview with the Clinical Director for Respiratory Therapy on 12/5/17 at 4:05 PM stated that, "The Quality Control checks are to be completed monthly. During the month of November 2017 I was on leave and evidently it was not completed."

Review of the Policy titled "Blood Gas Machine (EPOC) QA (quality)" dated 10/1/14 revealed, "Three-Level Liquid QC (Quality Control) (Levels 1, 2, & 3) is performed, evaluated and documented monthly and PRN (as needed) with instrument concerns. Documentation is maintained in the (Facility) EPOC QA book."

B. Review of the last 6 months of the temperature and relative humidity log in the Respiratory Service work Room where the Arterial Blood Gas Machine is stored revealed:
- The month of November lacked documentation of the temperature and relative humidity for 8 of 30 days.
- The month of October lacked documentation of the temperature and relative humidity for 2 of 31 days.
- The month of August lacked documentation of the temperature and relative humidity for 2 of 31 days.
- The month of July lacked documentation of the temperature and relative humidity for 4 of 31 days.

An interview with the Clinical Director for Respiratory Therapy on 12/5/17 at 4:05 PM stated that, "There is no specific policy for the temperature and relative humidity log to be completed daily. It is the expected that it is consistently checked. My expectation is that the temperature and humidity be checked and documented every 24 hours. It is due to the machine and the cards used to run the Blood Gases are stored in this room." "I did check and we did run Blood Gases on patients at least half of the days that lacked documentation."