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Based on review of clinical record, review of hospital policies and procedure and staff interviews, the facility for one of three residents reviewed for falls (Resident #5), the hospital failed to ensure a safe environment. The findings include:


Review of the clinical record identified Resident #5 was admitted to the hospital on 1/20/10 with diagnoses that included multiple sclerosis, hypertension, neurogenic bladder and dysphasia. A nursing care plan dated 2/5/13 identified falls as a potential problem with interventions that included the provision of a night light and a call bell, to check the resident's wheelchair to ensure it was in proper working order before use, maintain a safe and clean environment, lock the bed and wheelchair breaks, remove all obstacles, and ensure the room is free of clutter. Physician ' s orders dated 3/1/13 directed Resident #5 ' s activity level as out of bed to the wheelchair with assistance. The fall risk assessment dated 4/2/13 identified Resident #5 was a high fall risk. The mini Mental Status Exam dated 4/18/13 identified a mild cognitive impairment. The facility documentation dated 4/25/13 at 6:08 PM indicated Resident #5 left the building on his own, was found by the kitchen staff after falling off the loading dock outside, approximately four feet off the ground, lying on his left side still secured in his electric wheelchair. The chains that were located at the end of the loading dock were left down and unsecured. Resident #5 did not lose consciousness and was transferred to an acute care setting on 4/25/13 at 6:55 PM. A Computerized Tomography (CT) scan of the head and cervical spine were completed and did not reveal intracranial hemorrhage or fractures. A three centimeter laceration of the left superior eye lid was noted that required closure with sutures and the resident was discharged back to the facility. Interview with the building superintendent on 9/9/14 at 1:00 PM identified the doors beyond the loading dock were not locked and several vendors used the loading dock at the facility. Further interview with the building superintendent indicated the vendors drop off supplies and do not necessarily sequester the staff on arrival or departure from the building. As a consequence, the chains that provided a barrier at the end of the loading dock may not be reattached causing a hazard for the residents. Interview with the Director of Nursing on 9/9/14 at 1:15 PM identified he was aware the chains and the facility door was left unsecured on 4/25/13. In addition he indicated the facility did not have a procedure to ensure the safety of the residents in the area where the loading dock was located. The hospital policy entitled falls directed in part that all residents would be screened for falls and would be care planned for their specific needs to prevent falls if they were identified at risk. Further review of the policy indicated fall prevention strategies included the environment must be maintained in a safe condition at all times and that every employee was responsible to assist with the prevention of patient falls.

Based on facility documentation and staff interviews the facility failed to ensure that quality data received from the respiratory department was incorporated into a program to improve patient care and services in a timely manner. The finding includes:

Interview with the respiratory supervisor on 9/8/14 at 2:00 PM identified the Department of Respiratory Services collected data related to compliance with the administration of nebulizer treatments in accordance with physician ' s orders. Review of the data provided to the quality department dated May of 2014 identified the facility was 86.25% compliant with the administration of nebulizer treatments. In June of 2014 the facility was 79.37 % compliant. The goal was to achieve 90% compliance. Interview with the Quality Coordinator and the Director of Nursing on 9/9/14 at 2:10 PM identified although respiratory data collection was presented to the quality committee in the month of May and June of 2014, the quality and respiratory department failed to implement opportunities for improvement and/or changes that would lead to improvement. Subsequent to the surveyor ' s inquiry the Quality Coordinator indicated she would re-educate the staff regarding the importance of compliance with the administration of nebulizer treatments and track performance to ensure that improvements are sustained.

Based on review of credential files, review of facility documentation, review of Medical Staff Meeting minutes, and interviews, the facility failed to ensure that Utilization Review was performed as per Federal regulation. The finding includes:


Review of facility credential files and/or review of patient records on 9/4/14, 9/5/14, 9/8/14 and 9/10/14 identified that the MD #1 directed care for patients at the facility. The Administrative and Medical Staff Committee list indicated that the MD #1 and APRN #1 were included as members of the Admission Screening & Respite Committee. Medical Staff Meeting minutes dated 7/2/14 noted that utilization review deficiencies for May and June were discussed. Interview with the Utilization Review Coordinator on 9/9/14 at 1:20 PM identified that the Admission Screening & Respite Committee was the Utilization Review Committee, and an APRN was not on the committee. Although the results of Utilization Review were consistently discussed at the medical staff meetings, the committee members did not consist of at least 2 physicians. In addition, the review was not performed by a physician who was not involved with the care of the patient. During the exit interview on 9/9/14 at 3:14 PM, the Person # 1 indicated that he/she believed that Utilization Review had been outsourced previously.

Based on tour of the facility, review of facility documentation, observations and interviews, the hospital failed to ensure that alcohol gel was not expired and was suitable for use and/or observation, review of facility policies and procedures, manufacturer ' s recommendations, and interviews for the use of point of care, blood glucose monitoring devices for more than one patient, the hospital failed to ensure sufficient cleaning of the device between each patient use in accordance with current infection control standards and/or failed to ensure that patient rehab equipment was clean and/or that the rehab department was monitored for infection control practices. The findings include:


1. Tour of the Clean Utility Room on the Special Care Unit (BU) with Nurse Manager #2 on 09/08/14 at 9:15 AM identified that 6 of 12 bottles of alcohol gel had expired in March of 2014. Subsequent to surveyor inquiry, the alcohol gel was removed from service.

2. Tour of the Special Care Unit (BU) and interview with Nurse Manager #2 on 09/08/14 at 9:45 AM identified that the hospital utilized a multi patient use glucometer for blood glucose monitoring. Manager #2 identified that the nursing staff cleaned the glucometer between each patient use with an alcohol wipe. Interview with Licensed Practical Nurse #2 on 09/09/14 at 9:50 AM identified that disinfectant towelettes are available but were used for gross contamination only.

Review of the manufacturer ' s Operator ' s Manual dated 1998 that the facility was following directed, in part, cleaning of the exterior surface recommended daily with a water moistened cloth or a sponge with mild detergent. Do not use any solvents.

A hospital policy entitled Blood Glucose Testing Precision PCx Procedure directed, in part, Cleaning 1. Daily cleaning of the exterior surface of the glucometer will be done when controls are performed. 2. Turn off monitor prior to cleaning. 3. Clean monitor with a water-moistened cloth or sponge and a mild detergent (hand dispenser soap). 4. Do not use solvents. 5. Do not immerse, flood with any liquid, or autoclave the monitor. 6. Document daily cleaning. The cleaning policy was observed to be posted next to the glucometer.

Review of Center for Medicare and Medicaid Services Standards for Infection Prevention for Fingerstick and Point of Care Testing Devices dated 03/06/13 identified that if a Point of Care device is used for more than one patient it should be cleaned and disinfected after every use. Additionally the Center for Disease Control (CDC) identified if blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacture ' s instruction, to prevent carry-over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared.


3. Tour of the Rehab department on 9/5/14 at 2:30 PM indicated that equipment for patient use included cold and hot packs and a paraffin bath. The paraffin bath was observed plugged into an outlet and ready for use. The observation also noted that the bath was filled with liquid paraffin and had black particles floating at the bottom of the bath. Interview with the Director of Rehab on 9/5/14 at 2:30 PM identified that the paraffin bath was not used often and was cleaned every 3 months when not used frequently. Review of the manufacturer's guidelines for the paraffin bath directed to clean the unit after every 40 treatments, when the paraffin is no longer clear, or whenever sediment accumulates on the bottom.

4. Tours of the facility on 9/5/14 and/or 9/8/15 identified that the facility had an on- site Rehab department and a remote Dietary department. Review of the infection control surveillance program noted that, although the IC Practitioner performed environmental rounds in the dietary department and patient units, the surveillance lacked documentation of rounds reformed in the rehab department. The ICP was unavailable for interview at the time of the survey. The facility Medical Staff By-Laws Rules and Regulations identified that the IC Committee shall be responsible, in part, for infection control in all phases of the healthcare facilities activities.