HospitalInspections.org

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

1) Failing to develop and establish policies and procedures addressing safety standards for adequate shielding of patients and personnel. See findings in tag A-0536.

2) Failing to ensure contracted Radiologic services were supervised by a qualified Radiologist on either a full-time, part-time or consulting basis as evidenced by failing to appoint a qualified Radiologist to supervise the hospital's Radiologic Services. See findings in tag A-0546.

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

1. Failing to ensure the development and implementation of policies/procedures relative to the prevention and control of the transmission of Clostridium difficile (C. diff.). 5 (#1, #20, #22, #24, #R1) patients from 7/05/14 through 11/15/14 tested positive for hospital acquired Clostridium difficile with 3 (#20, #22, #24) of the 5 patients being concurrent patients in the same hospital room; and

2. Failing to ensure staff followed infection control policies/procedures relative to the use of personal protection equipment (PPE) for patients who were on contact isolation precautions and relative to hand washing for patients who were on contact isolation precautions. (see findings in tag A-0749).

Based on review of medical records and interview, the Governing Body failed to ensure the members of the medical staff were held accountable to the Governing Body for the quality of care provided to the patients as evidenced by medical staff members not assessing and pronouncing death for 2 (#14, #16) of 2 deceased patients' medical records reviewed.:


Patient #14
Review of the medical record for Patient #14 revealed he was a 69 year old white male admitted to the hospital for sacral wounds on 4/10/14. Patient #14 also had a history of Atrial Fibrillation and Congestive Heart Failure. The patient expired at the hospital on 5/1/14. Further review of the medical record revealed the ambulance paramedics assisted with the code and the paramedics called S11MD at Hospital "B" to confirm and call the code at 11:36 p.m. on 5/1/14.

An interview was conducted with S1DON on 11/17/14 at 11:30 a.m. She reported S11MD did pronounce the death over the phone and he (S11MD) was not on the medical staff of the hospital. He was an emergency room physician at Hospital "B". She further reported no one from the hospital 's medical staff pronounced the patient's death.

Patient #16

Review of the medical record for Patient #16 revealed he was a 86 year old white male that was admitted to the hospital on 7/18/14 for Aspiration Pneumonia and an Urinary Tract Infection. He expired on 7/29/14 at the hospital. Further review of the medical record revealed the paramedics were called and administered epinephrine to the patient. The paramedics notified S12MD at Hospital "B" and he called the code and pronounced the patient dead over the phone.

An interview was conducted with S1DON on 11/17/14 at 2:30 p.m. She reported S12MD did pronounce the patient's death over the phone and he (S12MD) was not on the medical staff of the hospital. She said he was an emergency room physician at Hospital "B". She further reported no one from the hospital 's medical staff pronounced the patient's death.

Based on record review and interview, the hospital failed to ensure patients received care in a safe setting as evidenced by no staff being assigned to continuously monitor telemetry patients on the night shift. This deficient practice had the potential to affect 2 (#3, #7) of 6 current patients on census.
Findings:
Review of the hospital policy titled Telemetry monitoring, Policy Number: II.K.11.06, read in part:
D. All telemetry patients will be monitored through a central monitor located at the nurse ' s station by a competency verified RN, LPN/LVN or monitor technician.
II. 1. Cardiac rhythms will be monitored by qualified staff at all times. It is the responsibility of the assigned monitor technician to assure that a qualified individual covers in his/her absence during meal or break times. At no time is the central monitor to be left unattended. Any variance from this must be reported to the DON and physician immediately.

Review of the inpatients' medical records revealed Patient #3 and Patient #7 were currently receiving telemetry monitoring.

Review of the nurse staffing grid revealed 9 or less patients only required 1 LPN and 1 RN on the night shift. The current census at the hospital was 6 patients.

In an interview on 11/18/14 at 8:15 a.m. with S2Quality, she said she did not have any monitor technicians at night. S2Quality verified the nurses at night were not assigned to be responsible for the telemetry monitor and there was not always a third staff member at night.

In an interview on 11/18/14 at 10:00 a.m. with S1DON, she said at night when the census was low, the hospital worked with two staff members. S1DON said no staff member at night was assigned to the telemetry monitor. S1DON verified if both of the nurses were providing patient care, nobody would be monitoring the telemetry patients.

Based on record review and interview, the hospital failed to ensure the QAPI (Quality Assessment and Performance Improvement) program provided accurate information for patient safety as evidenced by the drug error rate provided by the contract pharmacy being inaccurate or incomplete. Findings:

Review of the hospital's policy for Pharmacy Performance Improvement Activities, Policy Number: N.14. 04. 01 revealed in part, The pharmacy shall participate in facility wide performance improvement activities. Pharmacy staff shall, as necessary, collaborate in planning, designing, measuring, assessing, and improving performance...Cooperative Effort, the pharmacy shall participate in cross-departmental, cross-discipline, cooperative efforts to improve performance.

Review of the Event Category Scorecard for 2014 revealed the following medication errors reported by pharmacy in 2014: January: 0, February: 0, March: 10, April: 10, May: 10, June: 11, July: 2, and August: 2.

Review of the August Event Reports for medication errors revealed the contract pharmacy reported a physician medication order being faxed 3 times as an error and a medication being overlooked by the nurse initially, but found and administered to the patient correctly and on time as an error.

Review of the hospital's Medication Errors policy, Policy Number N.14.14.03 revealed in part, Example of Medication Errors, Examples of medication errors include, but are not limited to:
A. Wrong patient
B. Wrong medication
C. Wrong dose (greater or less than prescribed)
D. Wrong rate of infusion
E. Wrong route
F. Wrong dosage form
G. Wrong date or time
H. Patient has a stated allergy to the medication
I. Medication is not ordered
J. Extra dose (in addition to a scheduled dose or administered after the medication is discontinued).
K. Dose administered outside parameters
L. Omission of a dose
M. Expired medication
N. Contraindicated medication

An interview was conducted with S1DON on 11/18/14 at 10 a.m. She reported some months pharmacy didn't report any medication errors and other months they reported medication errors incorrectly.

An interview as conducted with S2Quality on 11/18/14 at 10:15 a.m. She reported in January and February 2014 the contract pharmacy did not report any medication errors and in others months they counted the nurses faxing admission orders on a patient more than once as a medication error. When questioned if the hospital's medication error rate and information was accurate, she reported she felt the medication error rate was inaccurate.

Based on record review and interview, the governing body failed to ensure that the hospital's QAPI (Quality Assessment and Performance Improvement) program reflected the hospital's organization and services as evidenced by not having all hospital departments and services, including those services provided by contractual agreements, included in the hospital's QAPI program. Findings:

Review of the hospital's policy, ABG (Arterial Blood Gas) Laboratory Director, Policy Number: IV.S. 19. 01, revealed in part, The ABG laboratory director's responsibilities include the following: 14. Ensure that the quality control and quality assurance programs are established and maintained to assure the quality of ABG laboratory services provided and to identify failures in quality as they occur.

Review of the hospital's Quality Assurance Program revealed no indicators for the respiratory department and the contracted linen services and no indications these services were involved in the hospital's QAPI program.

An interview was conducted with S2Quality on 11/17/14 at 3 p.m. She reported the contracted linen service and the respiratory department were not involved in the hospital's QAPI program.

Based on interview and record review, the registered nurse (RN) failed to ensure the supervision of nursing care provided to each patient as evidenced by entering wound care orders in the medical record without first obtaining authorization from the prescribing and/or admitting practitioner. This was identified for 2 (#2,#9) of 2 ( #2,#9) patients sampled.
Findings:
Patient #2:
Review of Patient #2 ' s medical record revealed an admission date of 10/29/14 and admission diagnoses of Osteomyelitis, Cellulitis and Diabetic Foot Ulcer. Further review revealed the following co-morbidities: Chronic Obstructive Pulmonary Disease, and Diabetes Mellitus Type II.
Review of Patient #2's Admit Physician Orders, dated 10/29/14, revealed Wound Care Nurse: Evaluate and Treat had been selected from a list of optional admission orders.

Review of Patient #2's Wound Care Nurse Consult documentation, dated 10/31/14, revealed the patient had a right great toe Diabetic foot ulcer. Further review revealed orders for wound treatment/dressings.

Additional review of Patient #2 ' s wound care order revealed the order had been signed by S13WoundCare on 10/31/14. The wound care orders were signed by the MD on 11/3/14. The orders were not documented as a telephone order read back and verified or as verbal orders.

Review of Patient #2's Wound Care Nurse Consult documentation, dated 11/10/14, revealed orders for wound treatment/dressings for the patient ' s right great toe wound.

Additional review of Patient #2 ' s wound care order revealed the order had been signed by S13WoundCare on 11/10/14. The wound care orders were signed by the MD on 11/12/14. The orders were not documented as a telephone order read back and verified or as verbal orders.


Patient #9

Review of Patient #9 ' s medical record revealed an admission date of 9/23/14 and admission diagnoses of Protein Malnutrition, Urinary Tract Infection, Anemia, Diabetes Mellitus and Hypertension.

Review of Patient #9's Admit Physician Orders, dated 9/23/14, revealed Wound Care Nurse: Evaluate and Treat had been selected from a list of optional admission orders.

Review of Patient #9's Wound Care Nurse Consult documentation, dated 10/2/14, revealed the patient had the following wounds: right knee and left great toe. Further review revealed two separate orders for wound treatment/dressings for the patient ' s wounds, which had been written by the wound care nurse.

Additional review of Patient #9 ' s wound care orders (2 separate orders dated 10/2/14) revealed the two orders had been signed by S13WoundCare on 10/2/14. The two wound care orders were signed by the MD on 10/13/14. The orders were not documented as telephone order read back and verified or as verbal orders.

In an interview on 11/18/14 at 12:07 p.m. with S1DON, she confirmed the two patients admitting MD had selected wound care nurse evaluate and treat on the admit orders. She said the wound care nurse would have then evaluated the patient ' s wound and ordered/initiated wound care treatments based upon his assessment. S1DON reviewed the wound treatment orders and she agreed the orders were not documented as verbal/telephone orders. She verified wound care had been initiated without first obtaining prior authorization from the prescribing and/or admitting practitioner.

Based on record review and interview, the hospital failed to ensure the skill and competence of all individuals providing patient care as evidenced by failing to maintain documented evidence of employee orientation, skills competency and performance evaluation of contracted nursing personnel.
Findings:

Review of the hospital's personnel files revealed no documented evidence of employee orientation, skills competency and performance evaluation of contracted nursing personnel.

In an interview on 11/13/14 at 2:06 p.m. with S2Quality, she said the hospital did not have any documented competencies, training or evaluations on the agency nurses. S2Quality said the hospital relied on the agency to determine competence of the nurses.

Based on record review and interview, the hospital failed to ensure non-employee registered nurses working as charge nurses were supervised by an appropriately qualified hospital-employed RN.
Findings:
Review of the hospital schedules for 10/14 and 11/14 revealed 4 nights (10/18/14, 10/19/14, 10/31/14 and 11/5/14) where an agency registered nurse (RN) and a staff licensed practical nurse (LPN) were the only 2 licensed staff working in the hospital. Further review revealed on 10/28/14 an agency RN worked with 2 staff LPNs.

In an interview on 11/13/14 at 1:56 p.m. with S1DON, she verified the above mentioned dates in October and November only had agency RNs and staff LPNs working at night. S1DON also said the LPNs were full time and would supervise and help the RNs. S1DON verified there was not a staff RN at night to supervise the agency RNs.

Based on record review and interview, the hospital failed to ensure drugs and biologicals were administered according to current nursing standards and physician orders for 3 (Patient #6, Patient #10, Patient #11) of 12 medical records reviewed for medication administration out of a sample of 30. Findings:

Review of the Lippincott Nursing Drug Guide presented by S1DON as the drug resource manual the nurses are instructed to utilize revealed under interventions for the drug Digoxin, the resource guide instructed the nurse to monitor the patient's apical pulse for 1 minute before administering; hold if pulse lower than 60 beats/minute in adults.

Patient #6
Patient #6 was admitted to the hospital on 10/8/14 with the diagnoses of Tibia/Fibula Fx (fracture) with history of UTI (Urinary Tract Infection) and Atrial Fibrillation.

Review of the Physician's Orders dated 11/3/14 at 9:20 a.m. revealed an order for Digoxin 125 mcg (micrograms) po (by month) EOD (every other day) and daily prior to the 11/3/14 order.

Review of Patient #6's MAR (Medication Administration Record) revealed Digoxin 125 mcg was administered on 10/17, 10/18, 10/19, 11/4 and 11/6/14 at 9:00 a.m. without the patient's apical pulse being assessed. Review of the Vital Signs and the Intake and Output record revealed routine vital signs were assessed at 6 a.m. and 6 p.m.

An interview was conducted on S1DON on 11/14/14 at 11 a.m. She reported the patient's apical pulse should had been monitored prior to the administration of the Digoxin. She further reported a reminder use to be on the MARs (Medication Administration Record) to remind the nurses to check the patient's apical pulse prior to administration. S1DON reported she did not realize pharmacy had not put the reminder of the patient's MAR.

Patient #10
Review of the medical record for Patient #10 revealed she was an 87 year old female that had been admitted on 9/12/14 for Severe Malnutrition status post PEG (percutaneous endoscopic gastrostomy) tube placement.

Review of the Physician's Orders for Patient #10 revealed an order dated 9/25/14 at 00:45 a.m. for Clonidine 0.1 mg (milligram) per peg tube PRN (as needed) for B/P > 160 (blood pressure greater than 160).

Review of the Vital Signs Intake and Output Records for Patient #10 revealed a blood pressure documented of 172/100 at 6:00 a.m. on 9/28/14.

Review of the MAR (medication administration record) for Patient #10 dated 9/28/14 revealed no documentation of Clonidine HCl 0.1mg having been documented as being administered for a systolic blood pressure of 172. Further review revealed no documentation of the medication being administered or the physician being notified.

Patient #11
Review of Patient #11's History and Physical revealed she was a 65 year old female admitted to the hospital on 9/25/14 with the diagnoses of Sepsis, Dehydration and Hypertension.

Review of Patient #11's Physician Orders revealed an order dated 10/27/14 at 2:00 p.m. of Clonidine 0.2 mg (milligrams) po (by mouth) every 8 hour prn (as needed) for SBP (Systolic Blood Pressure) > (greater than) 160.

Review of Patient #11's Vital Signs and Intake and Output Record dated 11/3/14 revealed her blood pressure was 165/85 at 6 a.m.

Review of Patient #11's MAR for 11/3/14 revealed Clonidine 0.2 mg po every 8 hour prn for SBP > 160 was not administered from 10/31 to 11/3/14.

An interview was conducted with S1DON on 11/14/14 at 12:30 p.m. She reported after review of the patient's medical record and the Omnicell (medication dispensing machine) record, Clonidine was not administered to the patient as ordered by the physician.




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30984

Based on record review and interview the hospital failed to ensure that medical record entries were authenticated, dated and timed, in written or electronic form, by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures as evidenced by:
1) Failing to ensure that medical record entries were authenticated, dated, and/or timed for 6 (#2, #4, #9, #10, #15, #20) of 6 (#2, #4, #9, #10, #15, #20) sampled patients reviewed.
2) Failing to ensure that entries in the medical record were legible for 1 (S5LPN) of 3 (S5LPN, S9LPN, S14RN) records reviewed for date and time.
Findings:

Review of the hospital's Medical Staff Bylaws revealed in part: 5.1.2 All medical 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. 5.8.2 All orders for medication and treatment shall be dated, timed, written legibly, clearly, and completely. Illegible or improperly written orders will not be carried out until clarification is obtained, they are re-written and understood by a nurse. 5.8.3 All orders must be entered in the patient's record, dated, timed and signed by the member of the medical staff. 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. 5.9.1 All clinical entries in the patient's medical record shall be accurately dated, timed and authenticated.

1) Failing to ensure that medical record entries were authenticated, dated, and/or timed.

Patient #2:

Review of Patient #2's medical record revealed the following incomplete entries (orders were dated by other hospital staff):
Orders authenticated by the physician, but not dated and timed:
11/3/14:Vancomycin Order
Order was not authenticated by the physician (dated and/or timed by other staff members):
11/16/14: Vancomycin order.

Patient #4

Review of the Admission Orders for Patient #4 revealed S3MD had authenticated the orders but had not timed or dated his authentication.

Patient #9

Review of Patient #9's medical record revealed the following orders had not been authenticated , dated or timed by the physician (dated and/or timed by other staff members):
Orders authenticated, but not dated and timed:
9/26/14, 2:10 p.m.: Occupational Therapy Initial Evaluation and Physician ' s Orders
10/13/14: Physician Wound Care Orders: left great toe
10/13/14: Physician Wound Care Orders: right knee
10/13/14: Physician Wound Care Orders: right 1st met (metatarsal) head
Orders not authenticated, dated or timed:
10/20/14: Physician Wound Care Orders: left great toe
10/20/14: Physician Wound Care Orders: right knee
10/20/14: Physician Wound Care Orders: right 1st met (metatarsal) head

Patient #10

Review of the Occupational Therapy, Speech Therapy, and Physical Therapy Initial Therapy Evaluation and Physician Orders for Patient #10 revealed the orders had been signed by the physician, but had not been timed or dated.

Patient #15

Review of Patient #15's medical record revealed the following orders had not been authenticated, dated or timed by the physician (dated and/or timed by other staff members):
Orders not signed, dated or timed:
10/21/14 at 1:00 p.m.: Admit Physician Orders
10/24/14: Physical Therapy Evaluation/Treatment Plan Recommendations, Physician orders, and Discharge Summary.

Patient #20
Review of Patient #20's medical record revealed the following orders had not been dated and timed by the physician.
7/17/14 Discharge Orders
9/08/14 CBC (Complete Blood Count) and CMP (Complete Metabolic Profile) order
9/11/14 Discharge Orders for last hospitalization

In an interview on 11/14/14 at 10:23 a.m. with S2Quality, she said they have always had difficulty with physicians timing, dating and signing their orders. She said it is a sticky situation because it is difficult to suspend them since they are your bread and butter.


2) Failing to ensure that entries in the medical record were legible.

Review of documentation in Patient #4 ' s nursing notes by S5LPN between 7:00 p.m. on 11/12/14 and 6:00 a.m. on 11/13/14 revealed 13 entries. None of the entries were legible.

Review of the documentation in Patient #5 ' s nursing notes by S5LPN between 6:30 p.m. on 11/7/14 until 6:30 a.m. on 11/8/14 revealed 12 entries that were illegible.

Review of the medical record for Patient #16 ' s nursing notes by S5LPN between 10:20 p.m. on 7/28/14 and 2:10 a.m. on 7/29/14 revealed 8 entries that were illegible including a code situation.

Review on 11/17/14 at 9:45 a.m. by S1DON of the above mentioned nursing documentation by S5LPN revealed she could not read the handwriting in the medical records.

Review on 11/17/14 at 10:00 a.m. by S2Quality of the above mentioned nursing documentation by S5LPN revealed she could not read her handwriting on any of the entries in the medical records.

Based on record review and interview, the hospital failed to ensure all verbal orders were dated, timed and authenticated within 10 days for 5 (#6, #8,#11, #13 and #15 ) of 6 patients reviewed for verbal orders.

Findings:
Review of the hospital's Medical Staff Bylaws revealed in part, 5.8.9 All verbal orders must be signed within 48 hours.

Patient #6

Review of Patient #6 's medical record revealed the following verbal orders were not signed by the physician within 10 days.
10/14/14-Active Protein Supplement
10/31/14- D/C (discontinue) Digoxin
11/1/14- Decrease Lopressor to 25 mg (milligrams) tablet BID (twice a day).


Patient #8

Review of documents for Patient #8 titled PICC Placement Orders revealed a telephone order had been taken for a PICC (peripherally inserted central catheter) insertion on 5/7/14 but had never been authenticated by the physician.

Further review of the medical record for Patient #8 revealed a verbal order dated 5/11/14 at 10:20 a.m. for a Hemogram which had never been authenticated by the physician.

Patient #11

Review of Patient #11's medical record revealed the following verbal orders were not authenticated in 10 days:
11/3/14 Wound care orders for Coccyx
11/3/14 Wound care orders for Left Lateral Foot


Patient #13:

Review of the medical record for Patient #13 revealed the Admission Physician Orders had been written by telephone order on 9/17/14 at 1:40 p.m. Further review revealed the physician had never authenticated the order.


Patient #15:

Review of the medical record for Patient #15 revealed the Admission Physician Orders had been written as a telephone order VRB (verified, read back) on 10/21/14 at 13:00 (1:00 p.m.). Further review revealed the physician had never authenticated the order.

In an interview on 11/18/14 at 12:05 p.m. with S1DON, she said 85% of their orders at the hospital were verbal orders. She agreed that 85 % verbal orders was a large number of verbal orders. She confirmed the verbal orders had not been authenticated.




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30984

Based on record review and interview, the hospital failed to ensure a full-time, part-time or consulting pharmacist was responsible for developing, supervising and coordinating all of the activities of the pharmacy services.
Findings:
Review of the organizational chart for the hospital revealed the director of the pharmacy was listed as contracted Pharmacy " A " .
In an interview on 11/17/14 at 10:20 a.m. with S10InfusionPharmacist, she said she was over the infusion portion of Pharmacy " A " but she was not the director of pharmacy for the hospital.

In an interview on 11/17/14 at 10:30 a.m., S8Pharmacist said he was over the long term portion of contracted Pharmacy " A " and S10InfusionPharmacist was over the infusion portion of the pharmacy for the hospital.

In an interview on 11/17/14 at 11:15 a.m. with S2Quality, she said S4CorporatePharmacist was responsible for pharmacy policies, pharmacy and therapeutics committee and education. S2Quality said S8Pharmacist at contracted Pharmacy " A " was responsible for medication errors and came to the facility once per month to check expiration dates. She said S10Pharmacist was over the IV infusion part of Pharmacy " A " and neither she nor S8Pharmacist would participate in the pharmacy and therapeutics committee and did not update or review policies. S2Quality said there was no one pharmacist responsible for the pharmacy department.

Based on record review and interview, the hospital failed to ensure errors in medication administration were reported to the attending physician for 1 (Patient #21) of 2 patients (Patient #21 and #23) and documented in the medical record for 2 of 2 patients (Patient #21 and #23) reviewed for known medication errors out of a sample of 30 patients. Findings:

Review of the hospital's policy on Medication Errors, Policy Number N.14.14.03, revealed in part, Medication errors shall be reported in a timely manner to the practitioner who ordered the medication. If the practitioner who ordered the medication is unavailable, the error shall be reported to the attending practitioner or another responsible practitioner. The medication administered in error or omitted in error and the action taken shall be properly recorded in the patient's medical record.

Patient #21
Review of Patient #21 medical record revealed she was admitted to the hospital on 8/21/14 for a Right 4th Finger Laceration with Infection and Healing Stage II Pressure Ulcer.

Review of the Patient #21 medical record revealed she lost her IV (intravenous) access and missed two doses of Clindamycin 600 mg (milligram) IVPB (Intravenous Piggyback) on 08/28/14. Further review of the medical record revealed the physician was not notified of the missed IVPB antibiotics and the medication error was not documented in the patient's medical record.

An interview was conducted with S2Quality on 11/18/14 at 3:30 p.m. She reported the physician was not notified of the 2 missed antibiotics doses and the medication error was not documented in the patient's chart.


Patient #23

Patient #23 was admitted to the hospital on 7/29/14 with the diagnoses of Diabetic Ulcer Right Foot, Malnutrition, Hypertension and Congestive Heart Failure.

Review of the Physician Order dated 8/25/14 revealed an order to Draw PT/INR (Prothrombin time and International Normalized Ratio )and if < (less than) 2.0 then d/c (discontinue) Lovenox and start Xarelto 15 mg with evening meal.

Review of the MAR (Medication Administration Record) revealed the PT/INR was less than 2.0 and the Xarelto was not administered until 8/29/14.

An interview was conducted with S2Quality on 11/18/14 at 3:30 p.m. She reported with review of the medical record the physician was made aware of the delay, but the medication error was not documented in the medical record.

Based on policy/procedure review and interview the hospital failed to assure proper safety precautions were maintained against radiation hazards as evidenced by failing to develop and establish policies and procedures addressing safety standards for adequate shielding of patients and personnel.
Findings:

Review of the hospital's radiological services policies/procedures revealed no documented evidence of policies and procedures addressing safety standards for adequate shielding of patients and personnel.

In an interview on 11/13/14 at 1:30 p.m. with S1DON, she confirmed the hospital had no policies and procedures addressing safety standards for adequate shielding of patients and personnel.

Based on record review and interview, the hospital failed to ensure contracted Radiologic services were supervised by a qualified Radiologist on either a full-time, part-time or consulting basis as evidenced by failing to appoint a qualified Radiologist to supervise the hospital's Radiologic Services.
Findings:

Review of the hospital's organizational chart revealed no documented evidence that a credentialed Radiologist had been appointed by the Governing Body to supervise Radiology Services.

In an interview 11/13/14 at 10:30 a.m. with S2Quality, she confirmed the Governing Body had not appointed a Medical Director of Radiology.

Based on observation and interview, the hospital failed to ensure equipment was maintained to ensure an acceptable level of quality as evidenced by patients' beds having a nurse call feature on the handrails that was inoperable for 16 of 16 beds.
Findings:

Observations during the initial tour on 11/13/14 at 9:45 a.m. revealed all of the patients ' beds had a nurse call button on the handrails with either the shape of a red cross on the button or a silhouette of a nurse with the word "nurse" written on it.

In an interview on 11/13/14 at 9:55 a.m. with S1DON, she verified all of the patients' beds had nurse call buttons on the handrails that were not functioning. S1DON agreed patients that were confused or family members that had not been oriented to the call button on a cord from the wall may use the buttons on the handrail in an attempt to call a nurse for assistance or in an emergency.

Based on record review, observation and interview, the infection control officer:
1. Failed to ensure the development and implementation of policies/procedures relative to the prevention and control of the transmission of Clostridium difficile (C. diff.). 5 (#1, #20, #22, #24, #R1) patients from 7/05/14 through 11/15/14 tested positive for hospital acquired Clostridium difficile with 3 (#20, #22, #24) of the 5 patients being concurrent patients in the same hospital room;
2. Failed to ensure staff followed infection control policies/procedures relative to the use of personal protection equipment (PPE) for patients who were on contact isolation precautions and relative to hand washing for patients who were on contact isolation precautions; and

Findings:

1. Failing to ensure the development and implementation of policies/procedures relative to the prevention and control of the transmission of Clostridium difficile.

Review of documentation provided by S2Quality revealed the following 5 patients acquired C. diff. while they were patients in the hospital:
Patient #20 (Room #1) - Admitted on 6/6/14 and discharged on 7/17/14. She tested positive for C. diff. on 7/5/14.
Patient #22 (Room #1) - Admitted on 8/5/14 and discharged on 9/4/14. She tested positive for C. diff. on 8/12/14.
Patient #R1 (Room #2) - Admitted on 9/5/14 and discharged on 10/10/14. He tested positive for C. diff. on 9/23/14.
Patient #24 (Room #1) - Admitted on 9/22/14 and discharged on 10/31/14. She tested positive for C. diff. on 9/27/14.
Patient #1 (Room #3) - Admitted on 11/5/14 and is still a current patient. She tested positive for C. diff. on 11/15/14.

Review of a room history report for Room #1 revealed Patient #20, Patient #22 and Patient #24 were the last 3 patients in the room.

Review of the hospital's Clostridium difficile infection rate calculated per 1000 days revealed the rate for December 2013 was 5.3, March 2014 was 3.4, July 2014 was 4.3 and September 2014 was 4.2.

In an interview on 11/17/14 at 2:30 p.m. with S2Quality, she said she was the infection control officer at the hospital. She verified there had been 5 hospital acquired cases of C. diff. since 7/5/14. S2Quality said the hospital could not determine how the C. diff. had been spread between the patients. S2Quality also said there were 2 patients in Room #1 that had acquired C. diff. but there had been patients housed in the room between their stays. When S2Quality was shown the documentation that there were 3 concurrent patients in Room #1 that had acquired C. diff., S2Quality verified she had assumed there were patients housed in Room #1 between Patient #20, #22 and #24 because there was a time frame between their discharges and admissions.

Review of the infection control policies revealed no policies for controlling the spread of Clostridium difficile.

In an interview on 11/18/14 at 10:42 a.m., S2Quality said the hospital did not have any policies/procedures specific to C-Difficile. S2Quality verified the hospital contact isolation policies did not reference the different practices specific to C. diff. such as hand washing instead of antimicrobial gel usage and wiping surfaces and equipment with solutions that killed spores.


2. Failing to ensure staff followed infection control policies/procedures relative to the use of personal protection equipment (PPE) for patients who were on contact isolation precautions and relative to hand washing for patients who were on contact isolation precautions.

Review of the hospital policy titled Guidelines for Transmission Based Isolation Precautions, Policy Number: III.R.18.09, revealed in part:
A. Contact Precautions: Use Contact Precautions for Patients with known or suspected infections or evidence of syndromes that represent an increased risk for contact transmission.
Use of Personal Protective Equipment:
1. Gloves: Wear gloves whenever touching patient ' s skin or surfaces and articles in close proximity to the patient (e.g., medical equipment, bed rails). Don gloves upon entry into the room or cubicle.
2. Gowns: Wear a gown whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient. Don gown upon entry into the room or cubicle.
3. Removal of PPE: Remove gloves then gown and observe hand hygiene before leaving the patient-care environment.

In an observation on 11/14/14 at 9:17 a.m., S6Housekeeper was observed leaving Room #4 which contained a patient on contact isolation. S6Housekeeper was observed removing her gown and balling it up with bare hands and throwing it away. S6Housekeeper then donned clean gloves and a clean gown and went into Room #3 which was also a contact isolation patient with C. diff. S6Housekeeper did not wash or sanitize her hands between patients or rooms.
In an observation on 11/18/14 at 8:50 a.m., S5LPN was observed administering medications to Patient #4 who was on contact isolation. Further observation revealed she did not tie her gown in the back which allowed her scrubs to brush against the patient's bedrail and bedside table.

In an observation on 11/18/14 at 11:46 a.m., S14RN was performing patient care on Patient #4 who was on contact isolation (in Room #4). S14RN was in direct contact with the patient and her bed and was not wearing gloves or a gown.

In an observation on 11/18/14 at 12:05 p.m., S6Housekeeper was cleaning Room #3 (C. diff. positive patient) and pushed up the sleeves on her isolation gown to wash her hands. S6Housekeeper did not pull the sleeves down on the gown over her long sleeved undershirt while she cleaned the room. S6Housekeeper's undershirt was exposed from her elbows to her wrists. S6Housekeeper then removed her gown and gloves and went to obtain more garbage bags from a room on another hall without washing her hands. S6Housekeeper returned to Room #3 and donned new gloves and a new gown. Once again she pushed the sleeves up on her gown and exposed her undershirt as she finished cleaning the room.

In an observation on 11/18/14 at 12:20 p.m., S9LPN went into Room #4 and administered insulin to Patient #4 who was on contact isolation. S9LPN did not tie the back of her gown which caused her scrubs to come into contact with the bedside table.




30364

Based on record review and interview, the hospital failed to have a Director of Respiratory Care Services to supervise and administer the service properly. Finding:

Review of the organizational chart revealed no documentation of a Respiratory Director.

An interview was conducted with S1DON on 11/17/14 at 11 a.m.. She reported there was no Director of Respiratory Services and a physician is not credentialed by the Governing Board as the Respiratory Director. She further reported the prn (as needed) respiratory therapists that work at the hospital occasionally are supervised by herself (S1DON).