HospitalInspections.org

Based on review of documentation and interviews with facility staff, the facility failed to document in the personnel records that patient restraint training had been completed in accordance with facility policy as 7 of 9 nursing staff personnel files reviewed did not have patient restraint training or competency documented within the last year. This could have potentially resulted in nursing staff being unprepared to properly implement patient restraints should the need arise.
The findings were:
The facility policy entitled "Competency Testing Program" with a review date of 4/30/01 reflected in part "I. Purpose: Competency testing is designed to verify that nurses training shows the capability of achieving job requirements and performance standards ...III. Policy: Competency testing will be done on every member of the nursing staff of Bowie Memorial Hospital during orientation and thereafter annually. IV. A. Competency tests will be based on job description to identify knowledge requirement skills, and behaviors that are specific to the employee role ...Employee Competency Assessment, RN ...Procedures: Restraints ... Employee Competency Assessment, LVN ...Procedures: Restraints."
Nursing staff personnel files were reviewed on the afternoon of 7/8/14 and revealed the following last dates of competency documentation: LVN, Staff #10, 2011; LVN, Staff #11, 2011; RN, Staff #24, 2012; RN, staff #25, 2/13; LVN, staff #26, 1/13; RN, staff #27, 2012; RN, staff #28, 2012.
In an interview with the facility nursing director, staff #6 in the conference room on 7/8/14 at 4:15 pm, staff #6 acknowledged that documentation of competency testing was overdue in the above listed personnel files. Staff #6 was asked if the facility policy entitled "Competency Testing Program" with a review date of 4/30/01 was currently in force and staff #6 stated it was.

Based on review of records and interview with staff, the facility failed to ensure that the medical staff examined credentials of candidates for medical and affiliated staff membership and made recommendations to the governing body on the reappointment of 4 of 9 providers whose records were reviewed.

Findings were:

A review was conducted of 7 physician files and 2 certified registered nurse anesthetist (CRNA) files; these providers require the recommendation of the medical staff and credentials committee to the governing body in order to be reappointed and provide services in the hospital. The files of 3 physicians, Staff # 14, #15, #17, and of 1 CRNA, Staff #22, had incomplete recommendation forms.

The facility utilizes forms entitled REAPPOINTMENT TO AFFILIATED STAFF for CRNA appointments and REAPPOINTMENT TO MEDICAL STAFF for physicians. The 4 applicants with incomplete forms were applying for reappointment for 2014 - 2016. One of the forms contains 3 sections in which the Credentialing Committee Chairman, Chief of Medical Staff, and Governing Body Secretary choose whether to reappoint the provider with full or restricted privileges, or to deny reappointment. While the forms were signed and dated by the committee members, the reviewers failed to indicate their recommendations for Staff #14, #15, #17, and #22. A 2nd form is utilized in the reappointment process, and it includes the Credentials Committee recommendations about whether the provider's quality assurance file is acceptable or not; whether the professional competence is acceptable or not; whether the provider's ethics and conduct is acceptable or not; and whether the status of the provider's mental/physical health is acceptable or not. There are also areas in the form where the reviewer can include additional comments, and whether the reviewer recommends the privileges currently held or if there are other changes to the privileges recommended. This form was incomplete for 2 physicians (Staff # 14, #17) and 1 CRNA (Staff #22).
In-person interviews were conducted with the CEO, Staff #2, and the Director of Quality, Staff #10, the afternoon of 7/8/14. Both stated that the files of 3 physicians, Staff # 14, #15, #17, and of 1 CRNA, Staff #22, had incomplete reappointment recommendation forms.

Based on review of documentation and interviews with facility staff, the facility failed to document in the personnel records that competency testing had been completed in accordance with facility policy as 7 of 9 nursing staff personnel files reviewed did not have competency testing documented within the last year. This could have potentially resulted in nursing staff competence in providing patient care not being appropriately evaluated.
The findings were:
The facility policy entitled "Competency Testing Program" with a review date of 4/30/01 reflected in part "I. Purpose: Competency testing is designed to verify that nurses training shows the capability of achieving job requirements and performance standards ...III. Policy: Competency testing will be done on every member of the nursing staff of Bowie Memorial Hospital during orientation and thereafter annually. IV. A. Competency tests will be based on job description to identify knowledge requirement skills, and behaviors that are specific to the employee role ...Competencies will include criteria for age-specific testing ...Mandatory topics such as Safety, Infection Control, Universal Precautions, CPR will be included in annual testing."
Nursing staff personnel files were reviewed on the afternoon of 7/8/14 and revealed the following last dates of competency documentation: LVN, Staff #10, 2011; LVN, Staff #11, 2011; RN, Staff #24, 2012; RN, staff #25, 2/13; LVN, staff #26, 1/13; RN, staff #27, 2012; RN, staff #28, 2012.
In an interview with the facility nursing director, staff #6 in the conference room on 7/8/14 at 4:15 pm, staff #6 acknowledged that documentation of competency testing was overdue in the above listed personnel files. Staff #6 was asked if the facility policy entitled "Competency Testing Program" with a review date of 4/30/01 was currently in force and staff #6 stated it was.

Based on observation, document review, and interview with facility staff, the hospital failed to maintain supplies and equipment to ensure an acceptable level of safety and quality. Expired supplies were available for patient use in 3 areas [Emergency Department, Surgical and Outpatient Rehabilitation Department]. Expired wound care supplies were observed in patient care areas available for patient use and were a potential for harm due to possible less than optimal wound healing. Therapy equipment located in the Outpatient Rehabilitation Department had tears in the vinyl covering which exposed yellow foam underneath that made thorough cleaning and disinfection of the equipment cover impossible as the foam could not be properly cleaned and was a potential source of contamination and infection. Additional rehabilitation equipment was observed available for patient use with cracks in the seat that was a potential for patient harm as a result of possible skin injuries. Electric portable fans were observed in the Outpatient Rehabilitation Department available for patient use that had excessive grayish dust on the fan blades and encasements that was a potential for patient harm due to possible spread of infection. Unsecured oxygen cylinders were found in the radiology department and gas storage room which was not consistent with facility policy and potentially were a safety hazard if they fell over.

Findings Included:

On the afternoon of 7/7/14 a tour of the Emergency Department was conducted with the Total Quality Management Director, Staff #10. During the tour, 5 Tegaderm wound dressings with expiration dates of 2/14 were found.

In an interview on the afternoon of 7/7/14 with Total Quality Management Director, Staff #10, she verified the above supply was expired, and available for patient use.

On the afternoon of 7/7/14 a tour of the Surgical Department was conducted with the Director of Emergency Room and Surgery, Staff #3. During the tour of the Day Surgery Medication Room, 1 16 ounce bottle of Isopropyl alcohol with an expiration date of 1/14 was found.

An interview on the afternoon of 7/7/14 with the Director of Emergency Room and Surgery, Staff #3 she verified the above supply was expired and available for patient use.

On the morning of 7/8/14 a tour of the Outpatient Rehabilitation Department was conducted with the Rehabilitation Director, Staff #9. During the tour, the following expired supplies were found:
1 - Bottle of Curity Iodoform Packing strips, expired 9/12
1 - Bottle of Bioguard Packing Strips, expired 4/14
1 - Bottle of Bioguard Packing Strips, expired 5/14
1 - Bottle of Puracyn Wound and Skin Hydrogel, expired 5/13
5 - AquaCel packages, expired 10/13
1 - Box of 5 AquaCel with Hydrofiber wound dressings packages, expired 4/12
4 - AquaCel wound dressing packages, expired 11/12
5 - AquaCel wound dressing packages, expired 10/12
10- AquaCel wound dressing packages, expired 2/13
5 - AquaCel wound dressing packages, expired 3/14
2 - Versia CE wound dressing packages, expired 12/09
1 - Box of 5 Versiva Adhesive covering, expired 12/09
10- Versiva Wound dressing packages, expired 7/13
1 - Versiva wound dressing packages, expired 12,10
10- ComiDerm HCD wound dressing packages, expired 5/12
6 - DuoDerm Signal wound dressing packages, expired 11/10
1 - Box of 5 DuoDerm Signal wound dressings, expired 8/12
1 - Box of 20 DuoDerm wound dressings, expired 10/12
9- DuoDerm Extra Thin wound dressing packages, expired 6/11
11- CombiDerm Non-adhesive wound dressing packages, expired 8/09
7 - CombiDerm Non-adhesive wound dressing packages, expired 6/08
2 - CombiDerm Non-adhesive wound dressing packages, expired 7/09
1 - Box of ConvaTec, expired 6/13
1 - Scotchcast Plus 2 wound dressing package, expired 2007

A tour of the outpatient rehabilitation department was conducted on the morning of 7/8/14 in the company of the facility Director of Rehabilitation, Staff #9. Observation revealed the following findings of the therapy equipment available for patient use in the treatment area:
2 approximate two inch tears, 1 one inch tear, and 1 dime size tear observed in the covering with exposed foam below of a traction table. Also observed 1 approximate 7 inch by 7 inch taped area with the edges of the tape rolled up along the sides with a sticky adhesive present. There was an additional taped circular area around the facial opening in the head rest of the traction table.
3 approximate two inch cracks on the right front corner and 1 approximate four inch crack on the left front corner of an electric lift chair.
1 approximate two inch tear in the seat covering with sponge material below of the NuStep seated stepper.
2 approximate one inch holes in the covering with yellow sponge material below of 1 treatment table
13 of 13 electric portable fans were observed in the facility Outpatient Rehabilitation Department available for patient use that had excessive grayish dust on the fan blades and encasements that was a potential for patient harm due to possible spread of infection. One of the fans was observed blowing directly on a patient in the area.

During an in person interview with facility Director of Rehabilitation, Staff #9, on the morning of 7/8/14, these findings were confirmed. Staff #9 stated repairs of the above equipment was not in the budget. Staff #9 stated the facility housekeeping department was responsible for cleaning the fans in the patient care area.

The review of facility's policy entitled "Equipment Safety Preventive Maintenance" with a review date of 5/10 stated "Preventive maintenance will be performed on all equipment to prolong equipment life and to insure efficient operation and reliability of the equipment. This will be accomplished on an ongoing basis. Employee Care of Equipment After Use: The performance of routine cleaning and dusting of equipment shall receive high priority because it accomplishes three significant missions: Keep the dirt and dust, which will clog air circulation ducts and air filters, to a minimum."

The review of facility's policy entitled, "General Cleaning and Sanitation" with a review date of 5/10 stated "All patient and nonpatient rooms shall be thoroughly cleaned and/or disinfected, keeping in mind Standard Precautions and Infection control. ... These should include cleaning for all specialty areas including, but not limited to Surgery, Emergency Department, Central Services, etc., as well as, all patient care and patient care support areas.





29934

During a tour of the facility on the afternoon of 7/7/14 1 of 2 oxygen cylinders in the radiology department was found standing on the floor unsecured. The radiology technician, staff #23 acknowledged that the oxygen cylinder was unsecured.
During a tour of the facility on the morning of 7/8/14, 2 oxygen cylinders were found in the gas storage room standing on the floor unsecured. The facility manager, staff #8 acknowledged that the 2 oxygen cylinders were unsecured.
The facility policy entitled "Waste Gases Management Plan" with a review date of 4/01 reflected in part "A. Compressed Gas. 1. Tanks of compressed gases will be stored upright and chained or otherwise secured to a support system to minimize falling over."

Based on review of documentation and interviews with staff, the facility failed to provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident for 5 of 5 patient records reviewed. The Activity Director did not complete a comprehensive assessment or program of activities for Residents #14 - #18.

Findings were:
As stated in the facility Swing Bed policy and procedure manual, the Swing Bed Activities Director " will sign off and date and time his/her signature on the Activities Screening/Plan Sheet and the Swing-bed Assessment/Activity Report Sheet each time. " Additionally there is an attachment entitled ACTIVITIES PROGRAM ORIENTATION FOR ACTIVITY DESIGNEE. This form includes a personalized assessment for each resident to be utilized to determine the resident ' s interests and needs in order to establish an activities program for that resident.
A review was conducted of the medical records for Residents #14 - #18, who received Swing Bed services from the facility. The Activity Director, Staff #5, did not include a comprehensive assessment or document a program of activities for any of the residents whose records were reviewed.
An in-person interview was conducted with Staff #3 during review of the electronic records the morning of 7/8/14. Staff #3 stated that there was no comprehensive assessment or program of activities for Residents #14-18. In an in-person interview conducted the morning of 7/9/14, the Director of Swing Bed, Staff #5, stated that there was no comprehensive assessment or program of activities established for swing bed Residents #14-18.