HospitalInspections.org

Based on policy review, document review and staff interview, it was determined that for 32 of 32 inpatients on 4/5/19, the hospital failed to provide the patient or the patient's representative with an accurate phone number and address to file a grievance with the State agency. Findings included:

The hospital policy entitled "Complaint and Grievance Process" stated, "...The grievance procedure is included in the admission packet and...patient is also provided with...state survey agency contact information..."

During an interview on 4/8/19 at 1:30 PM, Chief Executive Officer (CEO) A reported that patients were advised of their right to file a grievance in the document included in the patient admission packet entitled, "Quality Concerns? We Want to hear about it".

Review of the document entitled "Quality Concerns? We Want to hear about it" revealed that the State Agency's address and telephone number were inaccurate.

This finding was confirmed by CEO A on 4/8/19 at 1:30 PM.

Based on medical record review, policy review and staff interview, it was determined that for 1 of 5 patients (Patient #5) in the sample, the registered nurse (RN) failed to supervise and evaluate the nursing care. Findings included:

The hospital policy entitled "Hourly Round and Patient Call Guidelines" stated, "...All patients should have an hourly round/observation conducted by clinical staff..."

The hospital policy entitled "Clinical Services Policy and Procedure" stated, "...Routines/Guidelines...Bedfast patients turned. Document position...Minimum Frequency every 2 hours..."

The hospital policy entitled "Orders, Physician" stated, "RN 'acknowledges' orders...When the RN acknowledges orders, the RN accepts responsibility for carrying out those orders..."

Review of the electronic health record for Patient #5 (admitted 1/24/19) revealed:
1. Physician order dated 1/25/19 documented: Turn patient every 2 hours

2. Nursing Flowsheets from 4/1 to 4/4/19 revealed:
a. No evidence the patient was turned every 2 hours for the following dates/times:
4/3/19: 7:30 PM to 2:00 AM on 4/4/19 (6 hours and 30 minutes)
4/4/19: 5:00 AM to 11:00 AM (6 hours) and 2:00 PM to 7:00 PM (5 hours)

These findings were confirmed by Director of Quality Management A on 4/8/19 between 3:50 PM and 4:15 PM.

b. No evidence that staff conducted an hourly round/observation for the following dates/times:
4/1/19: 5:00 PM
4/3/19: 12:00 PM, 4:00 PM and 6:00 PM
4/4/19: 11:00 AM to 3:00 PM (4 hours) and 4:00 PM to 7:00 PM (3 hours)

These findings were confirmed by RN B on 4/8/19 at 2:30 PM.

Based on observation, policy review and staff interview, it was determined that for 2 of 22 patients (Patient #'s 6 and 7) on contact precautions, the infection control officer failed to ensure that staff adhered to infection control measures. Findings included:

The hospital policy entitled "Contact/Contact Enteric Precautions" stated, "...A sign reading 'Contact Precautions' will be posted on the door and on the patient's chart...PPE (personal protective equipment) will be available at the entrance of the room...Gowns should be worn when soiling will be likely to occur or when contact with the patient or environmental surfaces that have been contaminated will occur...Gloves must be removed before leaving the room...Meal Tray Pick-up...This is a two person procedure...Staff member #1 will be in hallway with the tray cart receiving tray...Staff member #2 will be going into patient room to retrieve tray...Staff member #2 will perform HH (hand hygiene) and don PPE to enter room and pick up tray...Staff member #1 will push cart to doorway and open door to cart...Staff member #2 will place tray into cart not touching exterior of cart...Staff member #1 will close door to cart and push cart to next room...Staff member #2 will remove PPE and perform HH, then exit room..."

The hospital policy entitled "Hand Hygiene" stated, "...Effective Hand Hygiene is considered the basis for an effective Infection Control Program...hand hygiene...Before donning either sterile or non-sterile gloves...Between glove changes and after removing gloves..."

A. Patient #6

On 4/5/19 at 10:05 AM, Nursing Assistant A was observed in Patient #6's room, which was identified with a Contact Precautions sign:

- at bedside holding meal tray wearing gloves
- left room with meal tray
- placed meal tray on cart
- removed gloves
- disposed of gloves
- walked to nursing station

Nursing Assistant A failed to adhere to hospital contact precautions guidelines.

These findings were observed and confirmed by Director of Quality A on 4/5/19 at 10:05 AM.

B. Patient #7

On 4/5/19 at 12:34 PM, Nursing Assistant B was observed in Patient #7's room, which was identified with a Contact Precautions sign:

- at bedside wearing gloves
- left room
- removed gloves
- sanitized hands

Nursing Assistant B failed to adhere to hospital contact precautions guidelines.

These finding were observed and confirmed by Director of Quality A on 4/5/19 at 12:34 PM.