HospitalInspections.org

Based on record review and interview, the facility failed to assure all hospital departments and services were participating in the Quality Assessment Performance Improvement (QAPI) Program. Citing 3 of 12 facility departments. (Environmental Care (housekeeping), Maintenance, Linen and Laundry).

Findings include:
Review of Quality Assessment Performance Improvement Program on 7/2/2013 and 7/3/2013 revealed the following.
Review of Board of Directors Good Shepherd Medical Center-Linden regular meeting minutes for February 25, 2013 and April 29, 2013 documented the review of Good Shepherd Health System Annual Score Card. Facility departments and services were reviewed and included the following:
*Patient Sanitization
*Core Measures including Heart failure Appropriateness of Care, Pneumonia Appropriateness of Care, Immunizations, Out-Patient Core Measures.
*Clinical Indicators
*Hospital Acquired Conditions
*Finance
*Cardiac Rehabilitation services
*Diabetes Education
*Dietary Department
*Laboratory Department
*Pharmacy Department
*Therapy Services
*Respiratory Services
*Swing Bed
*Trauma/Emergency Services

Interview with staff #32 on 7/2/2013 at 2:00 pm confirmed the findings. Staff #32 advised in January 2013 the facility went to the "Good Shepherd Health System Scorecard" to collect data for the QAPI program. The use of the scorecard left off the collection of data from all contacted services at the facility. Prior to this change all departments were part of the QAPI Program.

Based on observation, interview and record review the facility failed to ensure a sanitary and orderly environment to prevent infections in 4 of 4 departments (Physical therapy room, Laboratory, Dietary, Emergency Department) and hallways of the main building.
This deficient practice had the potential to affect all patients.
Findings include:
1. During an observation of the Physical therapy room on 07/01/2013 starting at 10:40 a.m. the following was found:
* Expired Supplies
One tank of oxygen expired 07/24/2009;
ABD (abdominal) dressing pads expired 02/01/2010;
Five liter container of Ultrasound gel expired 03/2012;
Automated external defibrillator pads expired 05/22/2012;
BD Safety Glide Needle expired 04/2012 and 06/2012;
Silver Sulfadiazine 1% expired 09/2012;
Zinc Oxide 10% expired 09/2012;
Silver Sulfadiazine 1% expired 12/2012;
Phenytoin ointment 4% expired 01/2013 and had a label taped on it. There was no indication as to who prepared the ointment.
Scrub care Chlorohexidine Gluconate solution expired 02/2013;
Lidocaine expired 04/2013;
During an interview on 07/01/2013 at 12:20 p.m., Staff #4 and #38 confirmed the observations in the therapy room.
* A biohazard container which had soiled gloves in it was stored inside a metal cabinet with clean dressing supplies. It was stored on a shelf with bottles of saline, a pan of sterile packaged tools, unbagged 4 x 4 dressings were behind the container, boxes of alcohol pads, and bottles of wound cleanser.
* Rolls of foam pads were stacked in a corner and were unbagged. Staff #38 reported they were being used on patients who received lymphedema treatment.
* Boxes of dressing supplies were stored on a top shelf still in packing boxes, above other supplies and equipment, and in close proximity to the ceiling.
* Exercise equipment, therapy equipment dressing supplies were stored in boxes or open plastic bins on the floor.
* Four uncovered plastic baskets with patient dressing supplies were stored on top of a metal shelf.
* Review of a policy/procedure named "Cleaning Hydrocollator" dated 01/20/2009 revealed the hydrocollator would be cleaned once a month or more often if needed.
A "Col Pac Hydrocollator" had a label on it that read "Inspected and approved for use and no periodic inspection required." The Hydrocollator had ice packs in it and one of the bins had an approximate 2 inch thick coating of ice. The filter, back of the machine and the motor area had a coating of dust. Staff #38 reported she normally cleans the equipment, but she had never cleaned this one.
* A room marked "Housekeeping" had an open box of biohazard trash filled to top and was sitting next to a shelf of clean supplies. A mop bucket, broom, bottles of cleaning solution, clean biohazard bags, trash bag liners, duster, wash basin, rolls of toilet paper and Super Sani cloth wipes used to clean down the equipment was stored in the room. There was a hydrocollator stored in the room which had a buildup of rust. The portable whirlpool was also stored in the room and identified as being clean by Staff #38. The inside of the whirlpool had particles and the off- white base had particles and brown dried substance. The back door next to the "Housekeeping" room was propped open with a brick. An approximate half foot of the baseboard at the door was separated from the wall. There was a spider web and a dead spider at the baseboard near the door.
* Review of a rehabilitation cleaning schedule from January - June 2013 revealed monthly cleaning was suppose to be performed on the equipment. The following was documented:
A. Pariffin unit was cleaned 1 out of 6 months during this time.
B. Hot Pack Covers had no documentation of washing.
C. Hydrocollators (for hot packs) were cleaned 4 out of 6 months during this time. The Col hydrocollator was not listed as being cleaned.
D. Whirlpool had no documentation of cleaning.
During observation on 07/01/2013 at 10:40 a.m., a fluid therapy unit was also in the therapy room. This piece of equipment was not on the maintenance list for temperature checks and cleaning.
During an interview on 07/01/2013 at 12:20 p.m., Staff #4 and #38 confirmed the observations in the therapy room.
During an interview on 07/02/13 at 10:45 a.m., Staff #38 confirmed the fluid therapy unit was not on her list and it would be added.
During an interview on 07/01/13 at 1:48 p.m., Staff #33 reported they were having quality assurance committee meetings and therapy was only tracking two legally required indicators. They were therapy consults being completed within 24 hours after request and care plans signed within 48 hours. These two indicators had been tracked for the past 1-1/2 years. Staff #33 could not explain other aspects of performance or quality improvement activities that were being assessed in the area of therapy.
2. During an observation of the Laboratory department on 07/01/2013 at 2:53 p.m., 6 cabinets and 1 drawer had the doors missing and the contents were exposed. Staff #39 confirmed the missing doors on the cabinets.



28659

3. On 7/1/2013 in the morning during a tour of the building, the following observations were made. A 6- 7 inch break was observed in the wall just above the cove base across from the gift shop making sanitation of the wall surface impossible. Further observation revealed, a quarter size break in the wall, was observed, in the room used by the Emergency Department as a trauma room. The break in the trauma room wall was at the level of the bed making sanitation unlikely and placing patient's at risk for cross contamination. During the same tour, the floor at the junction of the front hall and the surgery hallway was observed with two holes in the tile that penetrated into the concrete slab and one hole that broke through the tile. The broken tile and concrete created a sanitation risk as well as a safety risk for falls. These findings were confirmed by staff #1 during the tour.
4. On 7/2/2013 in the morning while touring the dietary department the following observations were made. The upright freezer in the kitchen was observed with 3 corrugated shipping boxes of frozen food stored inside.
· "External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated materials serve as generators of and reservoirs for dust ". (AAMI ST46-Section 5.2 receiving items)
Further observation of the freezer vents and filter revealed a heavy accumulation of dust and sticky, oily residue on the vents. This was confirmed by staff # 7, the Dietary Manager (Mgr.) Continued tour observations revealed many condiments (strawberry flavoring, vanilla extract, seasonings) without a date opened marked on the container. Staff #7 could not insure the age or sanitary condition of the many condiments, which also had a sticky oily residue. A commercial Hobart mixer was observed to have a sticky oily residue on the surface. Staff #7 indicated the mixer was no longer used but it had not been removed from the kitchen. There were 2 holes, about the size of a man' s fist, cut in the ceiling. Staff #7 and Staff # 6 indicated the holes had been cut by the fire extinguisher company last year, but had never been repaired. The holes were adjacent to the food prep tables. The lateral side vent and filter for the ice machine was observed with a sticky oily residue and a heavy layer of lint attached. Observed in the dirty area of the dish room, a cinder block wall had a large area without paint. sticky oily residue harbors bacteria and broken paint exposing cinder block concrete can not be sanitized.
On 7/2/2013 after the tour of the kitchen in the office of the Dietary Mgr., an interview with staff #7 confirmed there was not a policy or written cleaning schedule in the kitchen for the freezer or ice machine. There also was no policy for placing the date opened on condiments.

Based on document review and interview the facility failed to ensure 1of 5 departments(Dietary Service) had policies to guide staff in the provision of safe and sanitary services.

On 7/2/2013 in the afternoon the Governing Body (GB) meeting minutes were review and the following was observed.

The meeting minutes for all months recorded( January-June) reflected two documents.
Document #1 recorded the date time and all staff present for the meeting.
Document #2 recorded topical index of all items presented at the GB meeting.

Further review of the GB meeting minutes did not reflect review of department policies and Procedures, or a review of the discussion, recommendations or action taken on any item brought before the GB.

On 7/2/2013, in the morning, while touring the dietary department the following observations were made. The upright freezer in the kitchen was observed with 3 corrugated shipping boxes of frozen food stored inside.
· "External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated materials serve as generators of and reservoirs for dust ". (AAMI ST46-Section 5.2 receiving items)
Further observation of the freezer vents and filter revealed a heavy accumulation of dust and sticky, oily residue on the vents. This was confirmed by staff # 7, the Dietary Manager (Mgr.) Continued tour observations revealed many condiments (strawberry flavoring, vanilla extract, seasonings) without a date opened marked on the container. Staff #7 could not insure the age or sanitary condition of the many condiments, which also had a sticky oily residue. A commercial Hobart mixer was observed to have a sticky oily residue on the surface. Staff #7 indicated the mixer was no longer used but it had not been removed from the kitchen. There were 2 holes, about the size of a man's fist, cut in the ceiling. Staff #7 and Staff # 6 indicated the hole had been cut by the fire extinguisher company last year, but had never been repaired. The holes were adjacent to the food prep tables. The lateral side vent and filter for the ice machine was observed with a sticky oily residue and a heavy layer of lint attached. Observed in the dirty area of the dish room, a cinder block wall had a large area without paint. sticky oily residue harbors bacteria and broken paint exposing cinder block concrete can not be sanitized.
On 7/2/2013 after the tour of the kitchen, in the office of the Dietary Mgr., an interview with staff #7 confirmed there was not a policy or written cleaning schedule in the kitchen for the freezer, ice machine or lower levels of food prep tables and storage tables. There also was no policy for placing the date opened on condiments.
The above observation and interview confirmed the dietary department failed to establish and maintain policies or procedures for routine cleaning of equipment ( freezers, ice machine, lower level prep and storage tables), failed to establish and maintain policies and procedures to date food preparation items such as strawberry extract, Vanilla extract and condiments such a seasonings and spices, and failed to establish and maintain a policy for the removal of and safe storage of food products after shipping.

The above lack of GB documentation confirmed members of the GB were unaware of the failure in the dietary department to maintain safety and sanitation that had the potential to affect all patients.

Based on observation, interview and record review the facility failed to ensure there was a current list of individuals who were able to remove drugs from 1 of 1 pharmacies after hours.
This deficient practice had the potential to affect all patients.
Findings include:
Review of a policy named "After Hours Access to Pharmacy" with an effective date of 04/08/09 revealed the following:
"The Pharmacy is not in operation 24 hours a day. When pharmacy personnel are absent, access to the pharmacy is restricted only to the Charge Nurse on duty. This nurse will have restricted access to a unique pass code for the pharmacy keyless door entry system. The code will be stored in the automated dispensing cabinet (Pyxis) and may be changed by the pharmacist as frequently as necessary to ensure the integrity of the pass code.
A listing of licensed nurses and their signature that may enter the pharmacy will be maintained".
During an interview on 07/02/13 at 10:00 a.m., Staff #32 reported the charge nurses had access to the pharmacy after hour by using a code which was placed in the Pyxis by pharmacy. There was no current list of staff who could come in the pharmacy because of the turnover in nursing staff. Staff #32 reported she needed to get with nursing to get an updated list.
During an observation on 07/02/13 at 10:40 a.m., Staff #26 opened up the Pyxis and removed the access code for the pharmacy. Staff # 26 reported the access code in the Pyxis was for all the charge nurses to use.

Based on interview and record review the facility failed to ensure policies and procedures were reviewed annually for 2 of 2 departments (Swing Bed and Laboratory).
This deficient practice could affect all patients.
Findings include:
1. Review of the Laboratory policy and procedure manual cover sheet revealed the following:
"This manual contains the policies and procedures for Laboratory Services. It is reviewed annually and revised as needed."
Documentation revealed the policies and procedures were last reviewed in 08/2011 (almost 2 years ago).
During an interview on 07/01/2013 at 4:00 p.m., Staff #39 confirmed the policies needed to be reviewed. Staff #39 said she was going to a meeting on 07/02/2013 to have them updated.
2. Review of the Swing bed policy and procedure manual cover sheet revealed the following:
"This manual contains the policies and procedures for Swing Bed. It is reviewed annually and revised as needed."
Documentation revealed the policies and procedures were last reviewed 06/14/2012 (over 1 year ago).
During an interview on 07/03/13/ at 9:25 a.m., Staff #4 confirmed the policies and procedures were due for review.

Based on observation, interview and record review the facility failed to ensure 1 of 2 therapy rooms were organized (Physical therapy room).
This deficient practice had the potential to affect all patients.
Findings include:
1. During an observation of the therapy room on 07/01/2013 starting at 10:40 a.m. the following was found:
* Expired Supplies
One tank of oxygen expired 07/24/2009;
ABD (abdominal) dressing pads expired 02/01/2010;
Five liter container of Ultrasound gel expired 03/2012;
Automated external defibrillator pads expired 05/22/2012;
BD Safety Glide Needle expired 04/2012 and 06/2012;
Silver Sulfadiazine 1% expired 09/2012;
Zinc Oxide 10% expired 09/2012;
Silver Sulfadiazine 1% expired 12/2012;
Phenytoin ointment 4% expired 01/2013 and had a label taped on it. There was no indication as to who prepared the ointment.
Scrub care Chlorohexidine Gluconate solution expired 02/2013;
Lidocaine expired 04/2013;
During an interview on 07/01/2013 at 12:20 p.m., Staff #4 and #38 confirmed the observations in the therapy room.
* A biohazard container which had soiled gloves in it was stored inside a metal cabinet with clean dressing supplies. It was stored on a shelf with bottles of saline, a pan of sterile packaged tools, unbagged 4 x 4 dressings were behind the container, boxes of alcohol pads, and bottles of wound cleanser.
* Rolls of foam pads were stacked in a corner and were unbagged. Staff #38 reported they were being used on patients who received lymphedema treatment.
* Boxes of dressing supplies were stored on a top shelf still in packing boxes, above other supplies and equipment, and in close proximity to the ceiling.
* Exercise equipment, therapy equipment dressing supplies were stored in boxes or open plastic bins on the floor.
* Four uncovered plastic baskets with patient dressing supplies were stored on top of a metal shelf.
* Review of a policy/procedure named "Cleaning Hydrocollator" dated 01/20/2009 revealed the hydrocollator would be cleaned once a month or more often if needed.
A "Col Pac Hydrocollator" had a label on it that read "Inspected and approved for use and no periodic inspection required." The Hydrocollator had ice packs in it and one of the bins had an approximate 2 inch thick coating of ice. The filter, back of the machine and the motor area had a coating of dust. Staff #38 reported she normally cleans the equipment, but she had never cleaned this one.
* A room marked "Housekeeping" had an open box of biohazard trash filled to top was sitting next to a shelf of clean supplies. A mop bucket, broom, bottles of cleaning solution, clean biohazard bags, trash bag liners, duster, wash basin, rolls of toilet paper and Super Sani cloth wipes used to clean down the equipment was stored in the room. There was a hydrocollator stored in the room which had a buildup of rust. The portable whirlpool was also stored in the room and identified as being clean by Staff #38. The inside of the whirlpool had particles and the off- white base had particles and brown dried substance. The back door next to the "Housekeeping" room was propped open with a brick. An approximate half foot of the baseboard at the door was separated from the wall. There was a spider web and a dead spider at the baseboard near the door.
* Review of a rehabilitation cleaning schedule from January - June 2013 revealed monthly cleaning was suppose to be performed on the equipment. The following was documented:
A. Pariffin unit was cleaned 1 out of 6 months during this time.
B. Hot Pack Covers had no documentation of washing.
C. Hydrocollators (for hot packs) were cleaned 4 out of 6 months during this time. The Col hydrocollator was not listed as being cleaned.
D. Whirlpool had no documentation of cleaning.
During observation on 07/01/2013 at 10:40 a.m., a fluid therapy unit was also in the therapy room. This piece of equipment was not on the maintenance list for temperature checks and cleaning.
During an interview on 07/01/2013 at 12:20 p.m., Staff #4 and #38 confirmed the observations in the therapy room.
During an interview on 07/02/13 at 10:45 a.m., Staff #38 confirmed the fluid therapy unit was not on her list and it would be added.
2. Review of the Texas Administrative Code Title 40, Part 1, Chapter 19, Subchapter D Rule 19.341 (a)(4)(D) revealed the following:
"A nurse call emergency switch(es) must be provided for resident use at each resident's toilet, bath, and shower. These switches must be usable by residents using the fixtures and by a collapsed resident lying on the floor."
Review of the Texas Administrative Code, Title 25, Part1, Chapter 133, Subchapter I, Rule 133.169 (g) Table 7 revealed Therapy Suites and patient bathrooms should be equipped with an emergency calling system.
During an observation on 07/01/2013 at 11:18 a.m., the patient bathroom in the therapy room did not have an emergency light. Staff #38 reported when patients are taken to the bathroom staff stand outside the door.
During an interview on 07/01/13 at 1:48 p.m., Staff #33 reported they were having quality assurance committee meetings and therapy was only tracking two legally required indicators. They were therapy consults being completed within 24 hours after request and care plans signed within 48 hours. These two indicators had been tracked for the past 1-1/2 years. Staff #33 could not explain other aspects of performance or quality improvement activities that were being assessed in the area of therapy.

Based on record review and interview the facility failed to ensure medical record entries were complete, dated, and timed. Citing 8 of 20 patient medical records reviewed. (Patient #1, 2, 9, 11, 12,15,19, and 20).

Findings include:
Review of patient medical records on 7/2/2013 and 7/3/2013 at 10:00 am in the conference room revealed the following:
1. Patient medical record #1 revealed order dated 3/9/2013 for patient admission to facility had no documentation of the date and time the order was written per physician. Verbal orders written on 3/9/2013 and 3/10/2013 had no documentation of date and time the physician authenticated the orders.
2. Patient medical record #2 revealed no documentation of date and time admission order was written per physician and no documentation of drug allergies. Verbal orders x 2 written on 3/10/2013 had no documentation of time and date of physician authentication of order.
3. Patient medical record #9 revealed no documentation of patient weight, advanced directive, and/or family history on emergency room record.
4. Patient medical record #10 revealed no documentation of patient weight, family history, and/or date and time of physician signature on the emergency room physical exam sheet.
5. Patient medical record #11 revealed no documentation of patient weight and/or documentation of immunization status on emergency room record.
6. Patient medical record #12 revealed no documentation of patient weight and/or family history on emergency room record.
7. Patient medial record #15 revealed no documentation of patient weight and/or family history on emergency room record.
8. Patient medical record #19 revealed no documentation of patient weight, advanced directive, and/or date and time of physician signature on physical exam sheet on emergency room record.
9. Patient medical record #20 revealed no documentation of patient weight, advanced directive, and/or discharge vital signs on emergency room record.

Review of the Good Shepherd Medical Center-Linden Medical Staff Rules and Regulations on 7/3/2013 revealed the following:
The following are the Medical Staff Rules and Regulation for Good Shepherd Medical Center-Linden, a Critical Access Hospital, adopted in accordance with the procedures in Article XIV of the Medical Staff Bylaws. Unless the content otherwise requires, each term used herein shall have the same meaning as ascribed thereto in the Medical Staff Bylaws.
Rule II- Medical Records
1. The attending physician shall be responsible for preparing a complete, legible, accurate, and current medical record for each patient, including present on admission medical information as defined by Medicare.
Rule III- General Conduct of Care
1. Except in emergency situations, a general consent form, and when indicated specific consent forms, shall be obtained and signed by or on behalf of every patient admitted to the Critical Access Hospital.
2. All orders for treatment shall be in writing, legible, timed, dated, and signed by the treating practitioner or physician practitioner involved in care or covering. Verbal orders may be written and signed by the Licensed Vocational or Registered Nurse. Pharmacists may accept verbal orders for medication and licensed technologists, therapists, or registered dietitians may accept verbal orders in their are of discipline. The verbal order shall read "V.O.R. by Dr. (name) and timed, dated, and signed by the receiving staff person. All orders shall be signed by a physician within forty-eight (48) hours.
Verbal/telephone orders are to be used infrequently and only when the member is not physically present to write an order or in an emergency situation.

Interview with staff # 31 on 7/3/2013 at 11:00 am confirmed the findings.

Based on interview and record review the facility failed to ensure residents had the capability to receive and send mail promptly on weekends.
This deficient practice had the potential to affect all residents admitted into swing bed status.
Findings include:
Review of an undated "Swing Bed Patient Rights" revealed an elderly person may send and receive unopened mail, and the person providing services shall ensure that the individual 's mail was sent and delivered promptly.
During an interview on 07/03/13 at 8:22 a.m., Staff #s' 4 and 8 reported the normal mail delivery service for the community was Monday- Saturday. They reported there was no one designated to deliver or accept mail for residents on Saturdays in the facility. The residents had to wait to Monday to get their mail. Staff #4 reported she would check with the CEO (Chief Executive Officer) to make sure this was the case.
During an interview on 07/03/13 at 9:25 a.m., Staff #4 reported no one received the mail on Saturdays for the residents. The facility would have to get a drop or post office box for the resident' s mail to correct the problem.