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Based on observation, record review, and interview, the facility failed to involve all contracted services in their quality assessment and performance improvement program in 15 of 31 contacted services (Administrative Representative, Case Management/Social Services, Radiology, EKG/cardiac, General Maintenance, Information Systems, Legal Services, Linen Services, Nutrition Consultation Services, Occupational Health, Rehabilitation Services, Respiratory Care, Risk Management & Safety, Security, Spiritual Services), failed to complete an incident report in 1 of 1 observation (patient #11) or analyze and track adverse patient events, failed to document measurable progress of their performance improvement projects in 2 of 3 performance improvement projects (Quality Review Indicators and Nipple Shield Use) and administration failed to maintain an ongoing program for quality improvement and patient safety that prioritizes, defines, and evaluates their performance improvement projects. These deficiencies have the potential to affect all patients receiving care at this hospital and all outpatient breast feeding outpatients.

Findings include:
The hospital failed to involve all contracted services in their quality assessment and performance improvement program (See A-0273).
The hospital failed to complete an incident report in 1 of 1 observation (patient #11) or analyze and track adverse patient events (See A-0286).
The hospital failed to document measurable progress of their performance improvement projects in 2 of 3 performance improvement projects (See A-0297).
The hospital administration failed to maintain an ongoing program for quality improvement and patient safety that prioritizes, defines, and evaluates their performance improvement projects (See A-309).
The cumulative affects of the systemic problems prevented the hospital from having an ongoing data driven QAPI (Quality Assessment and Program Improvement) program to ensure staff and departments function in a safe and effective manner.

A un-announced recertification survey was performed at Columbia Center (Birth Hospital) from 1/9/2017 through 1/13/2017. The facility was surveyed under the following regulations: 42 CFR 482.41 Condition of Participation for Physical Environment. The facility is required to be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. Seven deficiencies were found in the three smoke compartments located on the Terrace Level of a 5-Story building. These deficiencies would affect all patients, staff and visitors within these smoke compartments. This condition was NOT MET as evidenced by the following seven deficiencies.

Findings Included:

1. 42 CFR 482.41(b) Standard: Safety from Fire was NOT MET as evidenced by the six deficiencies. Further review can be found under Section 709 within this report. The deficiencies include: K161 - Building Construction Type; K321 - Hazardous Areas; K353 - Sprinkler System - Maintenance & Testing; K363 - Corridor - Doors; K521 - Heating, Ventilating & Air Conditioning; K712 - Fire Drills; and K923 - Gas Equipment - Cylinder & Container Storage. These deficient practices were confirmed by staff C (PO Manager - Facilities & Maintenance Services) the facilities arm of Columbia Center (Birth Hospital) and staff A (President and CEO) of Columbia Center (Birth Hospital).


2. NFPA 101 (2012 edition) - Life Safety Code was NOT MET as evidenced by the one deficiency. Further review can be found under Section 709 within this report. This deficiency includes: K521 - Heating, Ventilating & Air Conditioning. This deficient practice was confirmed by staff C (PO Manager - Facilities & Maintenance Services) the facilities arm of Columbia Center (Birth Hospital) and staff A (President and CEO) of Columbia Center (Birth Hospital).

Based on record review and interview, the facility failed to provide the patient with written notice of findings, the steps taken on behalf of the patient, the results of the grievance process and the date of completion in 1 of 1 patient/family grievance (complaintant V). This deficiency could potentially affect all inpatients in this facility.

Findings include:

Review of policy Grievance Procedure, Notice of Patient Rights dated 8/2001, revised last 4/2011 stated in part under PROCESS II. D. "If the gievance is related to a patient quality of care ..., in addition to being reviewed by the Grievance Committee, it will be forwarded to the Medical Executive Committee in a timely manner, but in no case later than 7 days after receipt of the grievance... E. In its resolution, a member of the Grievance Committee will provide a written notice to the individual who filed the grievance. This notice will include the following information: 1. Name of a hospital contact person. 2. Brief explanation of steps taken on behalf of patient to investigate the grievance. 3. If appropriate, an action plan for improvement. 4. Date the investigation was completed. 5. Contact information of the agency to whom the patient may appeal if still unsatisfied. That appeal information will be provided within the body of the letter or by including an additional copy of the patient's rights brochure with the letter from the Grievance Committee."

Grievance reviewed from complainant V on 1/10/17 at 8:30 AM with Director of Patient Services I. Complaint was dated 12/27/15. Letter from Director of Patient Services I addressing complainant V was dated 1/04/16, stated "Please be assured that we take this matter very seriously and will investigate the circumstances you have described." Follow up note 1/8/16 "spoke with [clinic staff X] in office regarding [Patient #32's] letter, [clinic staff X] said she would speak to Dr. [W] regarding the family concern over Dr. [W]'s conduct." Follow-up note dated 1/12/16 "phone call to [Complainant V]. Discussed the follow up with [Complainant V], she was very appreciative for the follow up, and just hopeful that Dr. [W] will change his attitude and practice."

An interview was conducted with Director of Patient Services I on 1/10/17 at 8:30 AM. Director of Patient Services I stated copies of all information they had in the past three years was provided. Director of Patient Services I stated they did not log or track grievances other than the information provided. Director of Patient Services I stated this grievance was not taken to the Medical Executive Committee within 7 day of receipt.

Based on record review and interview, this facility failed to involve all contracted services in their quality assessment and performance improvement program in 15 of 31 contacted services (Administrative Representative, Case Management/Social Services, Radiology, EKG/cardiac, General Maintenance, Information Systems, Legal Services, Linen Services, Nutrition Consultation Services, Occupational Health, Rehabilitation Services, Respiratory Care, Risk Management & Safety, Security, Spiritual Services). This has the potential to affect all patients receiving care at this hospital (census on 1/9/17 (7), on 1/10/17 (6), on 1/11/17 (9), and 1/12/17 (10)).

Findings include:

The Columbia Center Birth Hospital Quality Review Committee policy #1700.64 dated 2/19/16 was reviewed on 1/11/17. This document states under "PURPOSE At least quarterly, conduct peer review and as appropriate, other forms of Health Services Review which impact the patients who receive services from CCBH [Columbia Center Birth Hospital]".

Review of Columbia Center Birth Hospital 2016 MSA [Master Service Agreement] with CSM [Columbia Saint Mary's] on 1/12/17 lists "Availability when called/needed" in 15 of 31 contracted services. No quality measures listed.

An interview was conducted with President/CEO A on 1/12/17 at 9:43 AM. President/CEO A stated that A works closely with some of the contracted services but uses other contracted services only as needed and is not aware of any quality assessment or performance improvement projects being worked on with the contracted services that list "Available when needed or Available when called" under Quality Measures.

Based on observation, record review, and interview, the facility failed to complete an incident report in 1 of 1 observation (patient #11) or analyze and track adverse patient events. This deficiency has the potential to affect all patients receiving care at this facility.

Findings include:

The Columbia Center Policy #1200.85 Titled Medication Error Tracking - Process Improvement dated 11/2005, revised last 6/2008, was reviewed 1/11/17 at 4:00 PM. Policy stated in part under Process: "Whenever an actual or potential medication error occurs, the following process is followed... Clinical caregiver documents error or potential error on...a Medication Occurrence and Tracking Form ... Clinical Leadership shall forward documentation to Risk Management for assignment of medication category and severity rating. Risk Management will collate medication error and potential medication error documentation... and create reports to submit to clinical leadership. Clinical Leadership will institute an improvement change using the PDCA (plan-do-check-act) cycle."

Review of report titled Columbia Center Birth Hospital Pharmacy QA [Quality Assurance] Document 2016 stated NONE under Medication Safety event reports for January thru July 2016, September thru November 2016. One incident documented for August 2016 and one in December 2016.

On 1/11/17 at 10:55 AM, observed bag of Penicillin 1 Gram mixed in 50 cc normal saline bag. Bag was labeled with patient #14 identifying sticker. Registered Nurse (RN) O spiked and hung bag for patient #11. Computer scan revealed error and medication was not given.

On 1/12/17 at 2:07 PM during an interview with Director of Patient Services I, the Medication Occurrence and Tracking Form was presented and reviewed. The Medication Occurrence and Tracking Form was completed by RN D. Director of Patient Services I stated that RN D filled out the incident report for RN O after telephone discussion with RN O on 1/12/17. Director of Patient Services I confirmed that the form was not completed until it was requested for review.

An interview was conducted with President/CEO A on 1/12/17 at 9:43 AM. When questioned about Risk Management report and recommendations for improvement, President/CEO A stated that incident reports, medication occurrence and tracking forms, and grievances are not sent to risk management, logged, or tracked. President/ CEO A stated there were so few of them, they were stored in the desk drawer for reference if needed.

Based on record review and interview the hospital failed to document measurable progress of their performance improvement projects in 2 of 3 performance improvement projects (Quality Review Indicators and Nipple Shield Use). This has the potential to affect all patients receiving care at the hospital and all breast feeding patients.

Findings include:

The Columbia Center Birth Hospital Quality Review Committee policy #1700.64 dated 2/19/16 was reviewed on 1/11/17. Policy states in part under PURPOSE "At least quarterly, conduct peer review and as appropriate, other forms of Health Services Review which impact the patients who receive services from CCBH " [Columbia Center Birth Hospital].

Review of Columbia Center Birth Hospital Indicator report dated July 2015-June 2016 on 1/12/17 at 9:40 AM. Information provided to Medical Executive Quality Assurance Committee and OB [Obstetrics] Section/Peds [Pediatric] Section last year. No comparison information provided.


Review of the printed PowerPoint "Nipple Shield Use" with pages marked, indicating information pulled during chart reviews. No measurable data provided.

An interview was conducted with President/CEO A on 1/12/17 at 9:43 AM. President/CEO A stated their Medical Executive Committee had recently approved changing from a physician centered to a multidisciplinary committee for their Quality Program. President/CEO A stated the goal was to provide and review the Hospital Indicator Report 2-3 times a year but states this has not been done yet. President/CEO A agreed that they do not measure the progress of their performance improvement projects quarterly.

Based on record review, and interview, administration failed to maintain an ongoing program for 1 of 1 quality improvement and patient safety program that prioritizes, defines, and evaluates their QAPI. This has the potential to affect all patients receiving care at this hospital.

Findings include:

The Columbia Center Birth Hospital Quality Review Committee policy #1700.64 dated 2/19/16 was reviewed on 1/11/17. This document states under PURPOSE "At least quarterly, conduct peer review and as appropriate, other forms of Health Services Review which impact the patients who receive services from CCBH [Columbia Center Birth Hospital]". This policy does not define it's performance improvement (PI) projects, how they will be prioritized and evaluated, or designate the number of PI projects conducted annually.

The Columbia Center Quality Review Indicators dated July 2015-June 2016 were reviewed on 1/12/17 at 9:43 AM with President/CEO A. President/CEO A states that this information is collected on each patient, but is not tracked or evaluated on a quarterly basis.

An interview was conducted with President/CEO A on 1/12/17 at 9:43 AM. President/CEO A stated their Medical Executive Committee had recently approved changing from a physician centered to a multidisciplinary committee for their Quality Program. President/CEO A stated that information on Performance Improvement projects were collected, but that these came in many different forms. President/CEO A could not illustrate how the PI projects were evaluated or defined, and did not have a list or number of PI projects that were conducted annually.

Based on interview and record review, the facility failed to ensure that the nursing staff individualize and maintain a current nursing care plan for each patient. The facility failed to individualize patient plans of care in 17 of 30 (patients #1, 3, 5, 6, 8, 9, 10, 11, 14, 16, 19, 25, 26, 27, 28, 29, 30 ) records reviewed and failed to review patient plans of care and update them in response to the assessments in 6 of 30 (patients #1, 9, 10, 16, 27, 28) records reviewed. This deficiency potentially affects all patients during the time of our survey, census on 1/9 (7), 1/10 (6), 1/11 (9) and 1/12 (9).

Findings include:

Per interview with Director of Patient Services I on 1/10/17 at 8:30 AM, Director of Patient Services I stated "care plans are initiated on every patient after delivery". At that time the needs are determined and care plans are individualized for mom and baby. The nurses are responsible to review the care plan once every shift".

Per review on 1/11/17 at 4:00 PM, of facility policy titled Plan for Providing Nursing Care, policy # 1000.20, dated 2/4/15, stated in part under III. The provision of nursing care is based on the patient's individual needs, standards of nursing practice, and clinical pathways, clinical guidelines and policies and procedures. The patient's age and stage of growth and development will be considered in the plan/provision of nursing care.

Per review of patient #1's medical record review with RN F on 1/10/17 at 10:30 AM with revealed a care plan initiated on 1/06/17 at 8:30 AM consisting of two problems titled "Comfort, Alteration in- Postpartum Related to Tissue trauma was circled. (Comfort) and Coping, Risk for Ineffective-Postpartum Related to maturation crisis of pregnancy/childbirth and assuming the role of motherhood and personal vulnerability. (Coping). The Comfort care plan checked "Instruct patient how to rate pain on scale of 0-10, identify acceptable pain level". Acceptable pain level was not documented. Under Expected Outcomes, the Coping care plan had "Patient will verbalize anxieties and emotional responses to childbirth/parenting" checked. Under expected Outcomes Other was written in "Pt has history of heroin drug abuse + diagnosis of bipolar, will demonstrate adequate coping mechanisms". No baseline of current coping mechanism was identified. Coping care plan for patient #1 was only reviewed one time on 1/10/17 at 4:50 AM.


Per review of patient #3's medical record review with RN F on 1/10/17 at 11:30 AM, revealed a care plan initiated on 1/08/17 at 6:00 PM consisting of one problem titled Feeding, Risk for Ineffective Pattern-Newborn Related to Lack of suck/swallow coordination, minimal intake after birth/sleepy. Under Expected Outcomes "If breastfeeding, Latch Score of 8 or higher prior to discharge" was checked. Care plan did not identify if patient was breast or bottle fed, did not list any latch scores.

Per review of patient #5's medical record review with RN F on 1/10/17 at 1:00 PM, revealed a care plan initiated on 1/09/17 at 3:55 PM consisting of one problem titled "Comfort, Alteration in-Postpartum Related to Tissue trauma, contractions. The Comfort care plan checked "Instruct patient how to rate pain on scale of 0-10, identify acceptable pain level". Patient #5's acceptable pain level was not documented.

Per review of patient #6's medical record review with RN F on 1/10/17 at 1:30 PM, revealed a care plan initiated on 1/09/17 at 4:00 PM consisting of one problem titled Injury, Risk for-Newborn Related to Adaptation to extrauterine life. No other care plan was on the chart and feeding was not addressed.

Per review of patient #8's medical record review with RN F on 1/10/17 at 2:45 PM, revealed a care plan initiated on 10/28/16 at 6:00 PM consisting of problems titled Injury, Risk for-Newborn Related to Adaptation to extrauterine life. No other care plan was on the chart and feeding was not addressed.

Per review of patient #9's medical record review with RN F on 1/10/17 at 3:05 PM, revealed a care plan initiated on 12/07/16 at 12:45 PM consisting of one problem titled "Comfort, Alteration in-Postpartum Related to Tissue trauma, uterine contractions, epidural site as evidenced by patient report of pain. The Comfort care plan checked "Instruct patient how to rate pain on scale of 0-10, identify acceptable pain level". Pt. #9's acceptable pain level was not documented. Care plan for patient #9 was not reviewed on 12/08/16.

Per review of patient #10's medical record review with RN F on 1/10/17 at 3:30 PM, revealed a care plan initiated on 12/07/16 at 12:45 PM consisting of one problem titled Infection, Risk for-Newborn Related to Thin, permeable skin. No other care plan was on the chart and feeding was not addressed. Care plan for patient #10 was not reviewed on 12/08/16.

Per review of patient #14's medical record review with RN D on 1/12/17 at 11:47 AM, revealed a care plan initiated on 1/11/17 at 2:00 PM consisting of one problem titled Injury, risk for- Postpartum Related to Biochemical, regulatory function, effects of anesthesia. No other care plan was on the chart and pain not addressed.


29963


Per review of patient #11's medical record review with RN D on 1/12/17 at 11:10 AM revealed a care plan initiated on 1/12/17 consisting of one problem titled "Comfort, Alteration in Post-Partum". The care plan did not indicate reason for pain. The Comfort care plan checked "Instruct patient how to rate pain on scale of 0-10, identify acceptable pain level". Patient #11's acceptable pain level was not documented.

Per review of patient #16's medical record review with RN D on 1/12/17 at 11:05 AM, pt. #16 was admitted for an induction delivery, had an epidural, and was treated with intravenous antibiotics. No care plan was initiated.

Per review of patient #19's medical record review with RN D on 1/12/17 at 10:50 AM, revealed a care plan initiated on 12/01/16 at 4:00 AM, consisting of one problem titled Injury, Risk for-Newborn Related to Adaptation to extrauterine life. There was no other care plan on the chart and feeding was not addressed.

Per review of patient #25's medical record review with RN K on 1/11/17 at 3:50 PM, pt. #25 was admitted for a vasectomy. Pt. #25's medical record revealed a paper titled "Perioperative Nursing Plan of Care" the form is a check off list including problems, interventions and expected outcomes. Patient #25's care plan was blank.

Per review of patient #26's medical record review with RN D on 1/12/17 at 10:50 AM, revealed a care plan initiated on 6/16/16 at 10:30 PM, consisting of one problem titled Injury, Risk for-Newborn Related to Adaptation to extrauterine life or anomalies. There was no other care plan on chart and feeding was not addressed.

Per review of patient #27's medical record review with RN D on 1/12/17 at 9:30 AM revealed being admitted with pre-term contraction following a fall. No care plan was initiated or reviewed.

Per review of patient #28's medical record review with RN D on 1/12/17 at 9:50 AM, pt. #28 was admitted for an induction delivery, was given an epidural, and was treated with intravenous antibiotics. There is no care plan to address pain or the use of antibiotics. Care plan for patient #28 was only reviewed one time on 8/17/16 at 2:05 PM.

Per review of patient #29's medical record review with RN D on 1/12/17 at 10:25 AM revealed a care plan initiated on 8/16/2016 consisting of one problem titled "Comfort, Alteration in Post-Partum". The care plan did not indicate reason for pain. The Comfort care plan checked "Instruct patient how to rate pain on scale of 0-10, identify acceptable pain level". Patient #29's acceptable pain level was not documented.

Per review of patient #30's medical record review with RN D on 1/12/17 at 9:45 AM revealed a care plan initiated on 12/1/16 consisting of one problem titled "Comfort, Alteration in Post-Partum". The Comfort care plan checked "Instruct patient how to rate pain on scale of 0-10, identify acceptable pain level". Patient #30's acceptable pain level was not documented.

Based on record review and interview, the facility failed to ensure consents are completed in 12 of 30 (pt. #1, 2, 5, 7, 9, 21, 22, 24, 18, 29, 16, 11) medical records reviewed. This deficiency has the potential to affect all patients receiving care at this facility.

Findings include:

Review of the facility policy titled Consent, for Treatment/Procedures #1700.55 dated 5/2005 reviewed last 8/2014 stated under II. Documentation and Duration of Consents D. "obtainig a patient's written consent should be executed at the time the physician explains the procedure to the patient... The Exact time the consent was executed should be noted...G. If a physician's own consent form is used... it should meet the same standards as the hospital's form".

Review of the facility policy titled Medical Records: Documentation Requirements for Medical Staff and Allied Health Professionals #1700.62 dated 6/2009, last revised on 10/2016 stated under I. Health Record Entries C. "Written enteries must be legible, permanently recorded in ink... authenticated by the author which must include signature, date of signature, and time of signature".

An interview was conducted with Director of Patient Services I and President/CEO A on 1/12/17 at 12:12 PM. President/CEO A stated it is expected that operation/procedure consents are to be filled out completely to include the name of the procedure, name of physician performing the procedure, signature of the patient or the patient's legal representative and the time and date they signed, signature of the physician reviewing the consent along with the date and time.

Patient #1's medical record was reviewed with RN F on 1/10/17 at 9:12 AM, revealed patient #1 had a cesarean delivery. Consent to Operation/Procedure with label identifying patient #1, the operation or procedure and MD signature, date and time left blank.

Patient #1's medical record, Consent to Operation/Procedure was reviewed with RN F on 1/10/17 at 9:12 AM, revealed Labor Epidural written under operation or procedure. The doctor performing the procedure was left blank and there was no MD signature, date and time.

Patient #2's medical record, Consent to Operation/Procedure was reviewed with RN F on 1/10/17 at 10:00 AM, revealed Labor Epidural written under operation or procedure. The doctor performing the procedure was left blank.

Patient #5's medical record, Consent to Operation/Procedure was reviewed with RN F on 1/10/17 at 1:00 PM, revealed Labor Epidural written under operation or procedure. The doctor performing the procedure was left blank.

Patient #7's medical record, Consent to Operation/Procedure was reviewed with RN F on 1/10/17 at 2:30 PM, revealed MD Y under physician authorized to perform surgery. CRNA Z witnessed, dated and timed procedure. MD signature, time and date left blank under "I have reviewed the risks, benefits and alternative modes of treatment with the above noted patient".

Patient #9's medical record, Consent to Operation/Procedure was reviewed with RN F on 1/10/17 at 3:05 PM, revealed Labor Epidural written under operation or procedure. The doctor performing the procedure was left blank.

Per review of patient #21's medical record was reviewed on 1/11/17 at 2:30 PM with RN K. The consent form indicated pt. #21 had a bilateral partial vasectomy on 12/2/16. The bottom of the form includes the following statement, "I have reviewed the risks, benefits, and alternative modes of treatment with the above noted patient." The form then has a line for the physician to sign, date, and time the consent. There is no physician signature, date or time noted.

Per review of patient #22's medical record was reviewed on 1/11/17 at 3:00 PM with RN K. The consent form indicated pt. #22 had a bilateral partial vasectomy on 12/16/16. The bottom of the form includes the following statement, "I have reviewed the risks, benefits, and alternative modes of treatment with the above noted patient." The form then has a line for the physician to sign, date, and time the consent. There is no physician signature, date or time noted.

Per review of patient #24's medical record was reviewed on 1/11/17 at 3:50 PM with RN K. The consent form indicated pt. #24 had a laparescopic tubal ligation on 12/9/16. The bottom of the form includes the following statement, "I have reviewed the risks, benefits, and alternative modes of treatment with the above noted patient." The form then has a line for the physician to sign, date, and time the consent. There is no date or time noted with the physicians signature.


Patient #18's medical record, Consent to Operation/Procedure was reviewed with Director of Patient Services I on 1/11/17 4:18 PM, revealed Labor Epidural written under operation or procedure. The doctor performing the procedure was left blank.

Per review of patient #29's medical record was reviewed on 1/12/17 at 10:25 AM with RN K. The consent form indicated pt. #29 received a labor epidural on 8/16/16. The name of the physician who completed the procedure was left blank.


Per review of patient #16's medical record was reviewed on 1/12/17 at 11:05 AM with RN K. The consent form indicated pt. #16 received a labor epidural on 11/12/16. The name of the physician who completed the procedure was left blank.


Per review of patient #11's medical record was reviewed on 1/12/17 at 11:10 AM with RN K. The consent form indicated pt. #11 had a primary cesarean section on 1/12/17. The bottom of the form includes the following statement, "I have reviewed the risks, benefits, and alternative modes of treatment with the above noted patient." The form then has a line for the physician to sign, date, and time the consent. There is no physician signature, date or time noted.


37419

Based on observation and interview, the hospital failed to ensure 1 of 2 crash carts (adult) were stored in a secured location. This could potentially affect all adult patients receiving care at his facility.

Findings include:

Per observation on 1/10/17 at 11:10 AM, Director of Patient Services I revealed the adult crash cart is stored in the hallway with a plastic breakaway lock. There are medications including Amiodaone, Atropine, Dopamine, Epinephrine, Midazolam, Naloxone, and Procainamide. There are also needles and syringes stored in the crash cart.

Per interview on 1/10/17 at 11:15 AM, Director of Patient Services I stated that the adult crash cart is stored in a manner that cannot be monitored by the staff at all times.

Based on interview and observation, the hospital failed to ensure medications and biologicals were properly stored and that outdated biologicals were not available for patient use in 2 of 4 areas (surgical area and patient rooms). This could potentially affect all patients receiving treatment at this facility.

Findings include:

Per interview on 1/10/17 at 11:30 PM, Director of Patient Services I stated that all rooms that store supplies are assigned to staff members and the staff are responsible to check supplies each month and discard items that have expired.

During tour of surgical services area with Obstetrics (Ob) technician BB on 1/9/17, beginning at 11:45 AM, noted the garbage cans in the 3 clean operating rooms (G50, G51, and G52), to contain packaged supplies. When Ob technician BB was asked why the clean surgical rooms have garbage cans of packaged supplies, Ob technician BB stated they must have checked the rooms this morning for expired supplies.

Per observation of the Post Anesthesia care unit (PACU) on 1/9/2017 at 12:00 PM noted in the Malignant Hyperthermia Cart.

(2) 1000 ml bags of Sterile Water with an expiration date of 11/2016
(2) boxes of 50% Dextrose 25 GM 0.5G/ml expired 1/1/2017
(6) BD Gold top Vacutainer tubes expired 12/16,
Decanter: (1) expired 12/15, (2) expired 6/12, (4) expired 2/16,
(1) Irrigation Tray 60 ml expired 2/16
(1) Foley Catheter expired 7/16
(1) Esophageal/rectal temp probe expired 4/16
(6) mini spike dispensing pin expired 5/12

Per observation of patient room #30, a Betadine PVP Scrub solution 7.5% Povidone-Iodine 4 oz, expiration date 4/2016 was found.

In room #32, a Betadine PVP Scrub solution 7.5% Povidone-Iodine 4 oz, expiration date 4/2016 was found.

Based on observation and interview, the facility failed to maintain an environment free of potential contamination to patient and other staff in 2 of 4 hospital areas (surgery area and soiled utility rooms). This has the potential to affect all patients receiving care at this hospital (census on 1/9/17 (7), on 1/10/17 (6), on 1/11/17 (9), and 1/12/17 (10)).


Findings include:


Per observation of soiled utility room (G1536) on 1/9/17 at 10:00 AM, noted vinyl floor covering to be buckling, open seams (welds have come apart), and baseboards have pulled away from the walls.

Per observation of soiled utility room (G1548) on 1/9/17 at 10:05 AM, noted the vinyl floor covering to have open seams and baseboards have pulled away from the walls.

Per observation on soiled utility room (G1548) on 1/10/17 at 9:00 AM, noted the door to be unlocked, stored inside the room was 2 biohazard labeled containers, 2 bottles of Virex, and chemical spill kit.


Per interview with President/CEO A on 1/10/17 at 10:00 AM, President/CEO A stated that the biohazard bins did not belong in the unlocked soiled utility room and agreed the chemicals need to be stored in a locked area.

Surgery Area

Per observation of the Surgical Area on 1/9/17 from 11:45 AM through 1:00 PM, the following observations were made:

Operating room (G50) noted the baseboards pulled away (corner) from the wall.

Operating room (G51) noted the baseboards pulled away (corner) from the wall.

Operating room (G52) noted the baseboards pulled away (corner) from the wall and separated seams in the flooring.

Post Anesthesia Care Unit (PACU) noted the baseboard pulling away from the wall in 3 corners of the room.

Sterile processing area (G1612) noted an area on the wall where the paint was removed, exposing drywall.

Peri-Operative room (G1610) noted the corner of wall with damage, paint was removed exposing a porous wall.

Per interview with Plant Operations C on 1/9/17 at 1:30 PM, C stated the flooring and the drywall needs to be repaired.

A un-announced recertification survey was performed at Columbia Center (Birth Hospital) from 1/9/2017 through 1/13/2017. The facility was surveyed under the following regulations: 42 CFR 482.41(b) Standard: Safety from Fire and NFPA 101 (2012 edition) - Life Safety Code. The facility is required to be constructed, arranged, and maintained to ensure life safety from fire to the patient, staff and visitors. Seven deficiencies were found in the three smoke compartments located on the Terrace Level of a 5-Story building. These deficiencies would affect all patients, staff and visitors within these three smoke compartments. This condition was NOT MET as evidenced by the following seven deficiencies.

Findings Included the Reference Tags: (See the K-tags for further information.)

K161 - Building Construction Type
K321 - Hazardous Areas
K353 - Sprinkler System - Maintenance & Testing
K363 - Corridor - Doors
K521 - Heating, Ventilating & Air Conditioning
K712 - Fire Drills
K923 - Gas Equipment - Cylinder & Container Storage

These deficient practices were confirmed by staff C (PO Manager - Facilities & Maintenance Services) the facilities arm of Columbia Center (Birth Hospital) and staff A (President and CEO) of Columbia Center (Birth Hospital).

Based on interview, record review, and observation, this facility failed to maintain an environment free of potential contamination to patients and other staff by not adhering to infection prevention expectations of the facility and nationally recognized standards of practice in 3 of 6 areas observed (Patient Rooms, Storage, and Surgical Services Area) involving 5 of 10 staff (Anesthesiologist Q, CRNA L, RN D, RN F, and Ob/Gyn T). This has the potential to affect all patients receiving care at this hospital (census on 1/9/17 (7), on 1/10/17 (6), on 1/11/17 (9), and 1/12/17 (10)).


Findings include:

Per interview with Director of Patient Services I on 1/10/17 at 12:45 PM, Director of Patient Services I stated the facility staff uses APIC [Association for Professionals in Infection Control and Epidemiology], AORN [Association of periOperative Registered Nurses], and CDC [Centers of Disease Control] to establish general infection control policies.

APIC Position Paper: Safe Injection, Infusion, and Medication Vial Practices in Health Care (2016) Disinfect catheter hubs, needleless connectors and injection ports before accessing. Use either an antiseptic containing port protector cap or vigorously apply mechanical friction with chlorhexidine/alcohol, sterile 70% isopropyl alcohol, or other approved disinfectant swab. Disinfect the rubber stopper of medication vials and the neck of glass ampules with sterile 70% alcohol before inserting a needle or breaking the ampule.

According to the APIC 3/6/2014, "Corrugated boxes should also not be present in clean storage rooms or clean supply rooms- items should be removed and placed on closed shelving or on pallets."

Per review of facility policy titled Hand Hygiene, policy #1300.27, dated 7/14, stated in part under B. Indications for Hand Hygiene- Before and after patient contact, before and after any invasive procedure, before donning gloves, and after removing gloves.

Per observation of the hospital rooms on 1/9/17 from 9:20 AM through 12:15 PM, the following observations were made:

Storage
Room G1543 storage area with 4 boxes of dried breast milk and cooler noted on the floor.

Unsterile Supplies
Opened 02 tubing with one end connected to open neonatal mask and the other connected to the 02 flowmeter on the wall in 8 rooms (Labor and Delivery Room 41, 42, and 44, OR Room G50, OR Room G51, Ultrasound room 1, Peri-op Room 2 (G1606), Peri-op Room 3 (G1610), Nursery, and Post Anesthesia Care Unit)


Procedure Observations
An observation of an emergency cesarean section was done on patient #14 on 1/11/17 beginning at 11:11 AM. At 11:53 AM Anesthesiologist Q removed the protective cap from two medication vials and did not cleanse the rubber septum's with alcohol prior to piercing with the syringe.

Observed a cesarean section done on Patient #14 on 1/11/17 beginning at 11:11 AM. At 11:53 AM Anesthesiologist Q did not disinfect the neck of a medication ampule prior to breaking it drawing it up and administering it to Patient #14.

On 1/11/17 at 3:16 PM observed an epidural (procedure done to numb body to help with pain during labor) on patient #11. After insertion, CRNA L removed the protective cap from a medication vial and did not cleanse the rubber septum with alcohol prior to piercing with the syringe before administering medication through the epidural line.

Hand Hygiene Observations
On 1/11/17 at 11:22 AM, baby #15 was delivered and handed to CRNA L. CRNA L had removed gloves, applied new gloves and did not perform hand hygiene between.

At 11:28 RN D was assisting the surgical team count sponges on patient #14, moved over to reposition Baby #15, RN D did not reglove or wash hands between.

On 1/10/17 at 9:06 AM observed Laboratory Specialist AA heel stick to obtain blood on Patient #4. When complete, RN F came to wrap Patient #4 in blanket. RN F did not sanitize hands prior to touching Patient #4.


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Per observation on 1/12/17 at 1:00 PM, Ob Tech S was assisting Dr. Ob/Gyn T with a circumcision for pt. #31. Dr. Ob/Gyn T entered the nursery with pt. #31 in a bassinet. No observation of hand hygiene noted by Dr. Ob/Gym T prior to procedure, after glove removal or at completion of procedure.

Findings of observation of care were shared with President/CEO A and Director of Patient Services I on 1/12/17 at 1:30 PM, A stated staff is required to complete hand hygiene prior to patient contact, prior to procedures, before donning gloves and after removing gloves.

Laundry and Supply Storage

Per review of facility policy titled Cubicle Curtain and Drape Cleaning, policy number 5.19, dated 11/1/15, stated in part under 4. Cubicle curtains and drapes can be vacuumed as needed, and should be changed per facility cleaning schedule. 5. Cubicle curtains are to be cycled cleaned semi annually an /or in accordance with hospital/legislative guidelines/recommendations.

Per interview with Environmental Director H on 1/10/17 at 8:45 AM, H stated the cubicle curtains are only cleaned when an isolation patient is discharged or when needed. Environmental Director H stated the facility does not have a cubicle cleaning schedule.


Per observation of Clean Linen Storage room (G2720) on 1/10/17 at 9:30 AM, noted 12 large plastic bins holding clean linen, which were uncovered.

Per interview with Environmental Director H on 1/10/17 at 9:30 AM, H stated being aware that clean linens needs to covered.

Per interview with President/CEO A on 1/10/17 at 10:00 AM, President/CEO A stated that the biohazard bins did not belong in the unlocked soiled utility room and agreed the chemicals need to be stored in a locked area.