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Based on review of 4 of 4 grievances filed with the hospital in the past 6 months, review of policy titled "Patient/Family Grievance" (reference #11-4.0.0, revised 10/08) and interview with the administrator and the DON, the hospital failed to follow their grievance policy to ensure written responses were sent to patients or their representatives informing them of the decisions made and the steps taken on their behalf to resolve their grievances. Findings:

Review of documentation provided by the administrator and the DON revealed there were 4 grievances filed by patients or family members during the past 6 months. Review of documentation by the administrator of the investigations to the allegations failed to reveal evidence that a written response was provided to the complainants after completing the investigations. In an interview on 8/31/2010 at 10:15 AM the administrator and the DON confirmed they had not provided a written response to each complainant after completing their investigations.

Review of hospital policy Patient/Family Grievance revealed "A patient grievance as defined by CMS (Centers for Medicare and Medicaid Services), is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by the staff present) by a patient, or the patient's representative, regarding the patient's care". Further review revealed, "A response to a grievance will be initiated (any action to begin the resolution process) within 24 hours during normal business hours, or the following business day if on the weekend".

This policy also indicated, "The hospital's Administrator/Assistant Administrator/Operations Officer will be responsible for the review, investigation and resolve (resolution) of all patient grievances. In its resolution of the grievance, the hospital will provide a written response of its decision within 7 days. The written response will identify the Administrator/Assistant Administrator/COO (Chief Operations Officer) as the contact person, the steps that will be taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of the completion of the process".

Based on review of the radiology contract with Hospital A and interview with the administrator, the hospital failed to have a written contract with the provider for radiology services which meet the needs of patients as evidenced by the contract not specifying a time frame for performing and reporting the results of radiology studies ordered immediately, or those done on a routine basis. Findings:

Review of the hospital's radiology contract with Hospital A (automatically renewed annually) failed to reveal time frames for performing and reporting immediate radiology studies, as well as those done on a routine basis. An interview with the hospital administrator on 8/31/2010 at 11:30 AM confirmed the findings.

Based on review of the laboratory services contract with host Hospital A and interview with the administrator, the hospital failed to have a written contract with Hospital A which meet the needs of patients as evidenced by the contract not specifying time frames for reporting results of laboratory studies that are ordered immediately, or those done on a routine basis. Findings:

Review of the hospital's laboratory services contract (automatically renewed annually) with host Hospital A failed to reveal time frames for reporting immediate laboratory results as well as those done on a routine basis. An interview with the hospital administrator on 8/31/2010 at 11:30 AM confirmed the findings.

Based on observation, review of policy titled "Guidelines For Isolation Precautions" (effective 7/2010), policy titled "Cleaning-occupied Isolation Rooms" (effective 5/2003), and staff interviews, the infection control officer failed to ensure all staff adhered to infection control policies and procedures to prevent the spread of infections as evidenced by: 1) the failure of nursing and physical therapy staff to adhere to hospital policies and procedures for isolation, and 2) the failure of housekeeping staff to adhere to hospital policies and procedures for cleaning isolation rooms. Findings:

1. On 8/30/2010 at 9:00 AM LPN (Licensed Practical Nurse) S1 was observed walking into room a (an isolation room) without wearing personal protective gear (mask, gown, gloves). At 9:05 AM S1 walked out of the isolation room, across the hall to her medication cart, and proceeded to prepare medications. S1 did not wash her hands as indicated on the isolation sign on the outer door to room a. LPN S1 took the medications out of the individual sealed containers and placed them in a small paper cup.

Review of the medical record revealed patient #6 was a 71 year-old admitted to room a on 8/14/2010 with diagnoses of encephalopathy and Lupus. Review of 8/25/2010 meningitis screen revealed patient #6's cerebral spinal fluid was positive for Group B Streptococcus and the patient was placed in contact isolation.

At 9:07 AM on 8/30/2010 CNA (certified nursing assistant) S2 was observed walking out of room a to the clean linen storage room. She removed a bundle of linen to stock the mobile linen cart in the hallway near room a. The CNA did not wash her hands after exiting room a and prior to handling the clean linen. S2 removed linen from the cart and entered room a without wearing personal protective gear.

On 8/30/2010 at 9:10 AM CNA S3 was observed coming out of room a, walked down the hall and entered room b without washing her hands. Review of the isolation sign on the door to room a revealed instructions to "wash hands" after leaving the room. CNA S3 was observed on 8/30/2010 at 9:15 AM dragging a yellow biohazard linen bag on the floor from room a, down the hall, and then she placed the bag it in the biohazard room.

On 8/30/2010 at 9:20 AM S4, PT (physical therapist) was observed walking into room a without wearing personal protective gear and began to massage patient #6's shoulders. At 9:30 AM housekeeper S5 was observed walking out of room a without gloves and carrying soiled linen. The linen was not contained in a biohazard bag.

Review of policy Guidelines For Isolation Precautions revealed to "Handle, transport, and process used linen soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures and contamination of clothing and that avoids transfer of microorganisms to other patients and environments". Further review revealed that "During the course of providing care for a patient, change gloves after having contact with infective material that may contain high concentrations of microorganisms. Remove gloves before leaving the patient's room and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent. Information will be made available to the patient, family, and healthcare workers if hand washing with soap and water is preferred to using a waterless antiseptic agent".

This policy also addresses that "A gown will always be worn when entering the room of a patient designated as requiring Maxum Contact Precautions. Remove the gown before leaving the patient's environment. After gown removal, ensure that clothing does not contact potentially contaminated environmental surfaces to avoid transfer of microorganisms to other patients of environments".

The DON confirmed in an interview on 8/30/2010 at 9:23 AM that S1, S2, S3 and S4 did not follow the hospital's policy for isolation precautions.

2. On 9/01/2010 at 9:25 AM S5 was observed removing 2 trash liners (a white trash liner and a red biohazard bag) from the bins in room a (isolation room) and placing them in the waste compartment on the housekeeping cart. While cleaning the room the sleeves on the housekeeper's gown eased down both shoulders onto the antecubital areas of her arms exposing the chest and breast area. At that time S5 reached down attempting to pull up her gown and the gloves rubbed across the top of her scrub suit. The housekeeper used a broom to clean the floor, swept the dust into a dust pan and then placed the pan with the debris on the side of the cart. After cleaning the floor S5 removed her gown and gloves and held them against her uniform before disposing them. S5 washed her hands with soap and water, pushed the cart down the hall to the housekeeping room and emptied the mop water. After cleaning the mop pail S5 failed to clean the equiptment stored on the housekeeping cart, clean the broom and empty the debris from the dust pan she used in room a.

Review of the policy for Cleaning-occupied Isolation Rooms revealed, "Emptied waste will be deposited in the appropriate container, red waste bags will be placed in biohazardous waste receptacles and clean bags will be placed in regular waste receptacles. Dust mop floor as per procedure (S5 used a regular broom to sweep room a). When leaving an isolation room, remove the protective equipment and dispose of the trash liner. Do not remove gloves at entrance of the room. Wash all supplies and equipment with approved germicidal solution. Place the mop head and linen in a bag. Pour out dirty solution in the bucket. Then remove gloves and place in trash liner. Wash hands upon completion of cleaning".

In an interview on 9/01/2010 at 10:00 AM the DON stated she is the manager of the housekeeping department. She confirmed that housekeeper S5 did not adhere to the hospital's policy for cleaning isolation rooms.

Based on record review and interview with the DON, the hospital failed to ensure the Housekeeping Department identified and tracked quality indicators as evidenced by the failure to include housekeeping in the hospital wide QA/PI program. Findings:

Review of the hospital QA/PI reports for the first (1/31/2010-3/31/2010) and second (4/30/2010-6/30/2010) quarters failed to reveal housekeeping, submitted quality data to the QA/PI Coordinator. In an interview on 8/31/2010 at 3:00 PM the DON stated that she is the hospital's QA/PI coordinator and is responsible for managing the housekeeping department. The DON further stated she does not track or submit quality data for housekeeping.