HospitalInspections.org

Based on record reviews and interviews, the hospital failed to ensure staff collected quality indicator data consistently and that the data collected was analyzed to assess the hospital's processes of care and the hospital's service and operations as evidenced by having incomplete information on the collection forms and failing to analyze collected data for 3 quality indicators reviewed.
Findings:

Review of the hospital policy titled "Performance Improvement Plan", presented as a current policy by S13Quality Officer, revealed that aggregating, analyzing, and evaluating data allows the hospital to draw conclusions about its performance in relation to a process or the nature of an outcome. Changes required to improve performance and reduce the risk of sentinel events are identified based on the analysis of data, either from ongoing monitoring or targeted study results.

Review of the quality indicator of "medication dosages that elicited an error" revealed the "Chart Reviews For Medication Variances" conducted by Offsite A had no documented evidence of results of 4 charts reviewed in February 2015, 2 charts reviewed in March 2015, 1 chart in April 2015, and 12 charts in June 2015.

Review of the quality indicators of "patients that develop pressure ulcers", "number of patient falls", and "medication dosages that elicited an error" revealed no documented evidence of an analysis of the data collected prior to initiating an action plan.

In an interview on 07/22/15 at 2:05 p.m., S1ADM (administrator) confirmed the chart audits conducted by Offsite A were incomplete.

In an interview on 07/22/15 at 9:30 a.m., S13Quality Officer confirmed he had no documented evidence to present of an analysis of the collected data that determined the root cause of the areas that were identified to below the expected targeted goal.

Based on record reviews and interviews, the hospital failed to ensure that action plans developed for identified opportunities for improvement were implemented at all locations as evidenced by implementing action plans at the location at which the quality indicator was below the target value and not implementing the plan hospital-wide.
Findings:

Review of the hospital policy titled "Performance Improvement Plan", presented as a current policy by S13Quality Officer, revealed that changes required to improve performance and reduce the risk of sentinel events are identified based on the analysis of data and actions to improve performance of new or existing processes, systems, and/or functions would be implemented to reduce or eliminate sentinel events.

Review of the quality indicators of "patients that develop pressure ulcers", "number of patient falls", and "medication dosages that elicited an error" revealed the main campus was below the targeted goal for medication errors in the first and second quarters of 2015. Further review revealed Offsite A was below the targeted goal for falls in the first and second quarters of 2015. Offsite B was below the targeted goal for medication errors in the second quarter of 2015. Further review revealed action plans were developed for each individual campus and not developed and implemented hospital-wide.

In an interview on 07/22/15 at 9:30 a.m., S1ADM (administrator) indicated the action plans are developed for each respective hospital campus for the quality indicator that is below the targeted goal and not developed and implemented hospital-wide. He further indicated the QAPI (quality assessment and performance improvement) data is collected and reported individually for each campus and is not aggregated as a hospital total until the annual review is done.

Based on record reviews and interviews, the hospital failed to ensure:
1) The hospital leadership set expectations for patient safety by adopting policies supporting a non-punitive approach to staff reporting of adverse patient events and medical errors as evidenced by having a policy that required employee counseling for all medication errors.
2) Staff was able to describe what was considered a near miss and needed to be reported internally for 1 (S11LPN [licensed practical nurse]) of 3 (S3LPN, S10LPN, S18RN [registered nurse]) nurses interviewed regarding quality assessment and performance improvement (QAPI).
3) Problems identified by the infection control officer were addressed through QAPI program activities as evidenced by failure to implement corrective action at all locations of the hospital.
4) Preventive actions for all identified serious preventable adverse events were implemented at all locations of the hospital as evidenced by implementing preventive action only at the campus at which the event occurred.
Findings:

1) The hospital leadership failed to set expectations for patient safety by adopting policies supporting a non-punitive approach to staff reporting of adverse patient events and medical errors:
Review of the hospital policy titled "Medication Variance", presented as a current policy by S1ADM (administrator), revealed that an employee counseling form would be completed by the employee's supervisor each time a licensed employee made a medication variance.

In an interview on 07/22/15 at 9:30 a.m., S13Quality Officer indicated the hospital's policy that required nurses who made medication variances to have an employee counseling form completed for each variance was of a punitive nature.

2) Staff was not able to describe what was considered a near miss and needed to be reported internally:
In an interview on 07/21/15 at 3:00 p.m., S11LPN (licensed practical nurse) was unable to describe what would be considered a near miss needing to be reported internally.

3) Problems identified by the infection control officer were not addressed through QAPI program activities:
In an interview on 07/22/15 at 9:30 a.m., S1ADM indicated the quality indicator data and required action plans, including those for infection control, are developed for each respective hospital campus when the quality indicator is below the targeted goal and not developed and implemented hospital-wide. He further indicated the QAPI (quality assessment and performance improvement) data is collected and reported individually for each campus and is not aggregated as a hospital total until the annual review is done.

4) Preventive actions for all identified serious preventable adverse events were not implemented at all locations of the hospital:
Review of 3 sentinel events revealed a patient experienced a decrease in blood pressure without notification of the physician that resulted in the need for bolus intravenous infusions at the main campus on 01/16/14, an electrical power loss of the host hospital of the main campus on 05/31/15 resulted in red emergency outlets not operating for approximately 5 minutes, and an elopement of a patient occurred at Offsite A on 06/03/15.

Review of documentation of the sentinel event of elopement at Offsite A revealed the action plan developed was implemented at Offsite A where the event occurred and not hospital-wide.

In an interview on 07/22/15 at 9:30 a.m., S13Quality Officer confirmed the action plan to address the possibility of elopement was implemented at Offsite A and not hospital-wide. He confirmed that each hospital campus has the potential for patients to elope.

25065

Based on record reviews, observations, and interviews, the hospital failed to ensure the infection control officer assured the system for controlling infections and communicable diseases of patients and personnel was implemented according to hospital policy and acceptable standards of infection control practices as evidenced by:

1) Failing to ensure S5Physician, S6RN (registered nurse), and S7RN donned PPE (personal protective equipment) prior to entering Patient #6's room who was ordered to be on contact precautions.

2) Failing to ensure that 2 of 2 housekeepers (S4HSK [housekeeper], S20HSK) observed during EVS (environmental services) cleaning implemented acceptable infection control practices when cleaning patient rooms and cleaning patient care equipment after use at the Main campus and at Offsite A campus, and failing to ensure that the Main campus hospital's EVS contracted service utilized EPA registered disinfectants while cleaning patient rooms.

3) Failing to ensure hand hygiene was performed by 1 of 1 respiratory therapist (S19RRT) after removing his gloves for 2 observations of breaches in hand hygiene practice during a patient's respiratory treatment at the main campus, and failing to ensure hand hygiene was performed by physicians and staff prior to and after patient contact and prior to donning gloves and after removing gloves for 14 observations of breaches in hand hygiene practices on 07/21/15 from 2:52 p.m. to 4:34 p.m. at Offsite A.

4) Failing to ensure the sign designating a patient placed on contact precautions was clearly visible as evidenced by having the sign taped to the patient's opened room door and not able to be seen when entering the room.

5) Failing to ensure the glucometer used for multiple patients was cleaned after each use before being stored.

6) Failing to ensure the infection control officer at Offsite A conducted surveillance of hand hygiene and use of PPE.


Findings:

A review of the Infection Control Plan, revised date 3/01/15, as provided by S2DON/IC as the current Infection Control Plan, revealed in part: The hospital shall comply with nationally recognized infection control practices and guidelines from the following nationally recognized organizations; CDC (Centers for Disease Control and Prevention), APIC (Association for Professionals in Infection Control and Epidemiology), SHEA (Society for Healthcare Epidemiology of America), AORN (Association of periOperative Registered Nurses) and OSHA (Occupational Health and Safety Administration).


1) Failing to ensure S5Physician, S6RN, and S7RN donned PPE prior to entering Patient #6's room who was ordered to be on contact precautions:

Review of the hospital policy titled "Isolation Precautions", presented as a current policy by S3ADON/IC (assistant director of nursing/infection control), revealed that the following was required when caring for patients on Contact Precautions:
a) wear gloves when entering the room;
b) change gloves after having contact with infective material;
c) remove gloves before leaving the patient's room and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent;
d) after glove removal and hand washing, ensure that hands do not touch potentially contaminated environmental surfaces or items in the patient's room;
e) wear a gown when entering the room if you anticipate that your clothing will have substantial contact with the patient, environmental surfaces, or items in the patient's room;
f) remove the gown before leaving the patient's environment.

Review of Patient #6's medical record revealed he was a 69 year old male admitted on 07/07/15 with a diagnosis of Cellulitis of the Right Hand status/post Incision and Drainage that was positive for MRSA (Methicillin Resistant Staphylococcus aureus). Further review revealed he was ordered to be on Contact Precautions.

Observation on 07/21/15 at 3:35 p.m. at Offsite A revealed S5Physician and S6RN entered Patient #6's room without donning an isolation gown and without performing hand hygiene. S5Physician removed Patient #6's dressing from his right hand and sat on Patient #6's bed to assess Patient #6's right hand. S5Physician was wearing a lab coat. Continuous observation revealed S7RN entered Patient #6's room without donning an isolation gown or gloves. Continuous observation revealed S5Physician and S6RN removed their gloves and used hand sanitizer before exiting Patient #6's room. Continuous observation revealed S5Physician and S6RN then entered another patient's room down the hall.

In an interview on 07/21/15 at 3:40 p.m., S6RN confirmed she and S5Physician did not don an isolation gown when they entered his room. She indicated she never wears PPE when she enters a patient's room who is on Contact Precautions.

In an interview on 07/21/15 at 4:48 p.m., S7RN confirmed Patient #6 was on Contact Precautions since his admission on 07/07/15. She confirmed that she, S5Physician, and S6RN did not follow the hospital's isolation precautions policy when they entered Patient #6's room without donning an isolation gown.


2) Failing to ensure that 2 of 2 housekeepers (S4HSK, S20HSK) observed during EVS (environmental services) cleaning implemented acceptable infection control practices when cleaning patient rooms and cleaning patient care equipment after use at the Main campus and at Offsite A campus, and failing to ensure that the Main campus hospital's EVS contracted service utilized EPA registered disinfectants while cleaning patient rooms:

Review of the hospital policy titled "Cleaning And Disinfecting Of Equipment", presented as a current policy by S3ADON/IC, revealed that all equipment that is visibly soiled will be cleaned with soap and water prior to disinfecting with an approved EPA (Environmental Protection Agency) approved disinfectant. At discharge, the electronic pumps, poles, flow meters, beds/mattresses, and wall suction gauges are cleaned and wiped with a disinfectant laden cloth during terminal cleaning of the room and stored in a clean area.

Review of the hospital policy titled "Cleaning-Patient Room Transfer/Discharge", presented as a current policy by S3ADON/IC, revealed wet floor signs were to be placed at the door to the room, and the floor was to be damp mopped with a hospital-approved germicidal solution by beginning at the farthest corner of the room working backwards toward the door including the bathroom and closet. Further review revealed the baseboards were to be disinfected also.

A review of the hospital-wide policies titled, "Cleaning-Patient Room Transfer/Discharge"; "Cleaning-Isolation Patient Room Discharge/Transfer"; "Cleaning-Patient Room (Occupied); and "Cleaning-Occupied Isolation Rooms", revealed in part: All patient rooms will be cleaned with a hospital approved germicidal solution. Damp mop with a hospital approved germicidal solution.

A review of the contracted EVS's procedure manual, provided by S24Director EVS, as the current procedure manual utilized by the contract EVS service for the hospital's Main campus revealed in part: Proper hand hygiene, cleaning product and equipment use is isolated to each room and EPA registered hospital disinfectants used in the proper manner are key features of our company.

Observation at Offsite A on 07/21/15 at 2:52 p.m. revealed S4HSK was mopping the floor in front of the housekeeping cart that was located outside Room 325 (a room from which a patient was recently discharged). She took a towel from the top of the cart and wiped the floor that she had just mopped and placed the contaminated towel on the top of the cart. S4HSK removed her gloves without performing hand hygiene. She took the broom from the cart and swept inside the entry area of Room 325 and then placed the broom with bristles facing upward on the cart. S4HSK donned gloves without performing hand hygiene. S4HSK mopped Room 325 around the bedside of the bed near the window and did not mop the entire room. She then removed her gloves and did not perform hand hygiene. At 2:58 p.m. S4HSK was observed removing a plastic-bagged-covered nebulizer and suction machine from the bed nearest the door in Room 325 and placed them on top of the housekeeping cart. She then unbagged the suction machine to wrap the electrical cord around the machine and rebagged it. S4HSK then placed the suction machine and nebulizer in the clean storage room.

In an interview on 07/21/15 at 2:58 p.m., S4HSK indicated she had cleaned the nebulizer and suction machine in Room 325 after the patient was discharged and before she had cleaned the room. She further indicated she usually cleans patient equipment in the patient's room, wraps in the plastic bag, and then cleans the room. She confirmed that she placed what she considered to be clean equipment on the dirty housekeeping cart and then placed in a clean storage room.

Observation on 07/21/15 at 3:04 p.m. revealed S4HSK went back to Room 325 to "make sure I got everything." She gloved without performing hand hygiene and removed a contaminated wet towel from the bathroom counter with no observation of S4HSK recleaning the counter. She removed her gloves without performing hand hygiene.

In an interview on 07/21/15 at 3:04 p.m., S4HSK indicated the towel was her "cleaning rag." She confirmed that she did not disinfect the bathroom counter of Room 325 after she removed the contaminated towel.

Observation on 07/21/15 at 3:07 p.m. revealed S4HSK rolled the housekeeping cart to the storage room and donned gloves without performing hand hygiene. She placed the soiled towels in a plastic bag and emptied the mop water in the sink.

In an interview on 07/21/15 at 3:07 p.m., S4HSK indicated she leaves the contaminated mop in the bucket on the housekeeping cart "in case they have a spill" after she leaves for the day.

In an interview on 07/21/15 at 3:10 p.m., S4HSK indicated she was the hospital's housekeeper and was contracted through the adjacent nursing home. She indicated she uses the same brush kept on the cart for cleaning small crevices and handrails. She confirmed that the brush is not cleaned in any way between use. She further indicated she changes the mop water after the third room cleaned but uses the same mop head to clean the entire hospital unless she has to clean a room of a patient on isolation precautions. S4HSK indicated she had received no training in the hospital's infection control practices by a hospital employee. She indicated she dried the floor in front of the cart near Room 325 with a towel, because she didn't want to leave the floor wet to get a wet floor sign.

In an interview on 07/21/15 at 3:42 p.m., S8HR (Human Resources) indicated the hospital did not keep a personnel file for the contracted housekeeper. She confirmed there was no documented evidence that education, training, and competency evaluation of S4HSK had been conducted by the hospital.

In an interview on 07/21/15 at 5:34 p.m., S3ADON/IC had no explanation or comments offered when informed of the above breaches in infection control practicies by S4HSK.


An observation on 7/21/15 at 2:40 p.m. was made of the Housekeeping supply carts and of the Housekeeping closet of the cleaning solutions (All Purpose Cleaner, Bowl Care Concentrate, Light Duty Cleaner 4, OxyCide) at the main campus. The All Purpose Cleaner, Bowl Care Concentrate and the Light Duty Cleaner 4 were not labeled on the bottles as being EPA registered disinfectants. A review of the bottle and the manufacturer's directions for the OxyCide, revealed it was an EPA registered disinfectant and it further revealed that the contact time (Kill time) was 5 (five) minutes.
An observation on 7/21/15 from 2:20 p.m. to 2:40 p.m. was made of S20HSK performing routine patient room cleaning in the Main campus. S20HSK was observed using (APC) "All Purpose Cleaner" on the room's mirrors, counter top surfaces and the chrome faucets in both the patient room and patient bathroom. S20HSK was observed removing her left glove and was observed continuing to clean with only one glove on her right hand. She was observed pouring "Bowl Care Concentrate" in the toilet bowl and cleaning the toilet bowl with a non-disposable toilet brush that was soaking in a container with "Bowl Care Concentrate" in it. S20HSK was observed returning to the patient room area and using the APC, re-cleaning the room's counter tops, then she returned to the bathroom and she cleaned the toilet itself, the shower area, the bathroom sink and then returned to the patient room area and cleaned the remainder of the patient room, all with only one glove on. S20HSK was then observed spraying OxyCide on select items in the room and bathroom and immediately using a dry towel to dry the areas after she sprayed them. S20HSK was further observed getting rags and supplies out of her cart in the hallway and unlocking and locking her cart with the same gloved hand and non-gloved hand. S20HSK was not observed changing her gloves or washing/sanitizing her hands when going from dirty tasks to clean tasks. S20HSK was observed completing the EVS cleaning of the patient room by mopping the floor with a single use mop head soaked in Light Duty Cleaner 4.
In an interview on 7/21/15 at 2:40 p.m. with S20HSK she was asked about her cleaning protocols for patient rooms. S20HSK indicated that she had a routine that she followed for all patient rooms, except isolation rooms, when she donned a cover gown also. S20HSK was asked about the non-disposable toilet bowl brush. She indicated that she used the brush until it got too worn or too dirty. S20HSK was asked about her cleaning solutions and if they were disinfectants. S20HSK indicated that she was not sure and that they were the same solutions used by all the EVS staff at the Main campus. S20HSK was asked what the contact time (Kill time) was for the OxyCide. She indicated that she did not know.
In an interview on 7/21/15 at 2:40 p.m. with S21HSK Supervisor, S22HSK Manager they were asked if they monitor housekeeping staff for proper cleaning protocols and acceptable infection control practices. They indicated that they randomly monitor the housekeepers. S21HSK Supervisor and S22HSK Manager were asked if the housekeeping cleaning solutions (All Purpose Cleaner, Bowl Care Concentrate, Light Duty Cleaner 4, OxyCide) utilized by the housekeeping staff were disinfectants and EPA registered. They indicated that they were not sure. S21HSK Supervisor and S22HSK Manager were asked what the contact time (Kill time) was for the OxyCide. They indicated that they were not sure.
In an interview on 7/22/15 at 10:30 p.m. with S24Director EVS he was asked if they monitor housekeeping staff for proper cleaning protocols and acceptable infection control practices. He indicated that they monitor the housekeepers randomly and orient them upon hire on proper room cleaning protocols. S24Director EVS was asked if the housekeeping cleaning solutions (All Purpose Cleaner, Bowl Care Concentrate, Light Duty Cleaner 4, and OxyCide) utilized by the his housekeeping staff were disinfectants and EPA registered. S24Director EVS reviewed a copy of the contracted EVS's procedure manual, provided by S24Director EVS, as the current procedure manual utilized by the contract EVS service for the hospital's Main campus. S24Director EVS referenced the section that revealed in part: EPA registered hospital disinfectants used in the proper manner are key features of our company. S24Director EVS later indicated that he was unable to provide EPA registration for 3 of the 4 cleaning solutions (All Purpose Cleaner, Bowl Care Concentrate, Light Duty Cleaner 4). S24Director EVS indicated that according to the manufacturer that there were no components in those 3 cleaners that were considered hazardous waste and that they did not require EPA registration since they were all "green" .

In an interview on 7/21/15 at 3:15 p.m. with S2DON/IC, she indicated that she was the Director of Nurses for all the campuses and that she was the designated Infection Control Officer for the Main campus. She further indicated that her ADONs (Assistant Director of Nurses) at the other campuses (Offsite A and Offsite B) were the designated Infection Control Officer for their respective campus. S2DON/IC was asked about the monitoring of the contracted housekeeping staff for acceptable infection control practices. She indicated that she performed random monitoring and would address infection control concerns individually with the housekeepers. S2DON/IC was asked if the housekeeping cleaning solutions (All Purpose Cleaner, Bowl Care Concentrate, Light Duty Cleaner 4, OxyCide) utilized by the contracted housekeeping staff were disinfectants and EPA registered. She indicated that she assumed that they were EPA registered disinfectants. S2DON/IC was made aware of the infection control breaches identified in the patient room cleaning observations with S20HSK. S2DON/IC indicated that the housekeeping staff working this week were not her usual housekeepers.

3) Failing to ensure hand hygiene was performed by 1 of 1 respiratory therapist (S19RRT) after removing his gloves for 2 observations of breaches in hand hygiene practice during a patient's respiratory treatment at the main campus, and failing to ensure hand hygiene was performed by physicians and staff prior to and after patient contact and prior to donning gloves and after removing gloves for 14 observations of breaches in hand hygiene practices on 07/21/15 from 2:52 p.m. to 4:34 p.m. at Offsite A:

A review of the hospital-wide policy titled, "Cleaning and Disinfectant of Equipment", provided by the S2DON/IC as the most current, revealed in part: An EPA registered disinfectant will be utilized to disinfect equipment to prevent the spread of infections.
A review of the AORN recommended practices, 2013 Edition, revealed in part: Stethoscopes should be cleaned/disinfected between patient use and should not be worn around the neck. Stethoscopes come into direct contact with patient's skin and clothing and provide an opportunity for transmission of microbes from patient to patient.
Review of the hospital policy titled "Hand Hygiene", presented as a current policy by S3ADON/IC, revealed that hands were to be decontaminated before inserting any invasive device that does not require a surgical procedure, after contact with a patient's intact skin, after contact with body fluids or excretions, mucous membranes, non-intact skin and wound dressings if hands are not visibly soiled, if moving from a contaminated body site to a clean body site during patient care, after contact with inanimate objects in the immediate vicinity of the patient, after removing gloves, and before eating and after using a restroom.

Review of "Guideline for Hand Hygiene in Health-Care Settings", contained in the "Morbidity and Mortality Weekly Report 10/25/01/Volume 51/Number RR-16" presented by the Centers for Disease Control and Prevention, revealed that hands were also to be decontaminated before having direct contact with patients.

An observation on 7/21/15 from 1:10 p.m. to 1:25 p.m. was made of S19RRT performing a respiratory treatment on a ventilator patient, Patient R4, in the patient's room. S19RRT was observed removing his gloves, on two occasions, to document the patient's respiratory treatment and S19RRT was not observed washing/sanitizing his hands after removing his gloves on those two occasions. A further observation was made of S19RRT checking the patient's breath sounds frequently during the respiratory treatment with his stethoscope and after Patient R4's respiratory treatment was completed S19RRT was not observed disinfecting his stethoscope and was observed placing it back around his neck.
In an interview on 7/21/15 at 1:25 p.m. with S19RRT, the observations were reviewed with him. S19RRT indicated that he did not think about washing/sanitizing his hands after he removed his gloves. S19RRT further indicated that he was not aware that a stethoscope had to be disinfected after use on a patient and that it was not supposed to be worn around the neck.
In an interview on 7/21/15 at 3:15 p.m. with S2DON/IC she was made aware of the observations of the Respiratory Therapist. S2DON/IC indicated that acceptable infection control practices were not followed.

Observation on 07/21/15 at 3:35 p.m. at Offsite A revealed S5Physician and S6RN entered Patient #6's room (on Contact Precautions) without donning an isolation gown and without performing hand hygiene.

Observation at Offsite A on 07/21/15 at 2:52 p.m. revealed S4HSK was mopping the floor in front of the housekeeping cart that was located outside Room 325 (a room from which a patient was recently discharged). She took a towel from the top of the cart and wiped the floor that she had just mopped and placed the contaminated towel on the top of the cart. S4HSK removed her gloves without performing hand hygiene. She took the broom from the cart and swept inside the entry area of Room 325 and then placed the broom with bristles facing upward on the cart. S4HSK donned gloves without performing hand hygiene. S4HSK mopped Room 325 and then removed her gloves and did not perform hand hygiene.

Observation on 07/21/15 at 3:04 p.m. revealed S4HSK went back to Room 325 to "make sure I got everything." She gloved without performing hand hygiene and removed a contaminated wet towel from the bathroom counter with no observation of S4HSK recleaning the counter. She removed her gloves without performing hand hygiene.

Observation on 07/21/15 at 3:07 p.m. revealed S4HSK rolled the housekeeping cart to the storage room and donned gloves without performing hand hygiene.

In an interview on 07/21/15 at 3:10 p.m., S4HSK indicated she was the hospital's housekeeper and was contracted through the adjacent nursing home. S4HSK indicated she had received no training in the hospital's infection control practices by a hospital employee.

In an interview on 07/21/15 at 5:34 p.m., S3ADON/IC had no explanation or comments offered when informed of the above breaches in hand hygiene by the physician, nurses, and housekeeping staff.


4) Failing to ensure the sign designating a patient placed on contact precautions was clearly visible as evidenced by having the sign taped to the patient's opened room door and not able to be seen when entering the room:

Review of the hospital policy titled "Isolation Precautions", presented as a current policy by S2ADON/IC, revealed that a transmission-based precaution sign (Contact or Maximum Contact) will be placed on the outside of any patient's room where an isolation precaution is warranted.

Observation at Offsite A on 07/21/15 at 3:35 p.m. revealed Patient #6's (who was on Contact Precautions) room door had a yellow sign that read "Contact Precautions". Further observation revealed the sign was not visible upon entering the room when the door was left in an open position. There was no observation of a "Contact Precautions" sign placed outside Patient #6's room as required by hospital policy.

In an interview on 07/21/15 at 4:48 p.m., S7RN confirmed the "Contact Precautions" sign was not easily visible when Patient #6's room door was left open.


5) Failing to ensure the glucometer used for multiple patients was cleaned after each use before being stored:

Review of the hospital policy titled "Cleaning And Disinfecting Of Equipment", presented as a current policy by S3ADON/IC, revealed that the blood glucose meter and case should be wiped with a disinfectant laden cloth before and after use on each patient.

Observation at Offsite A on 07/21/15 at 4:34 p.m. revealed S10LPN performed an Accucheck on Random Patient R2. Continuous observation revealed S10LPN did not clean the glucometer before placing it the drawer after use.

In an interview on 07/21/15 at 4:40 p.m., S10LPN confirmed he didn't clean the glucometer after he performed Random Patient R2's Accucheck.

Observation at Offsite B on 07/21/15 at 4:55 p.m., revealed S17LPN performed an Accucheck on Random Patient R7. Continuous observation revealed S17LPN removed the glucometer from the patient's room with a paper towel and placed the glucometer on a medication cart in the hall. S17LPN was observed to wipe the glucometer with 1 disinfectant wipe that was retrieved from a container on the cart. S17LPN was observed to pick up the glucometer and begin to walk down the hall toward the nurse's station. When asked what type of disinfectant wipe she used, she indicated the wipe was a PDI Sani Cloth and provided the container for review. Review of the label on the PDI Sani Cloth container revealed a 3 minute wet contact time was required for proper disinfection. The label indicated to use additional cloths to assure the 3 minute wet contact time. In an interview at the time of the observation with S17LPN, she confirmed she did not allow a 3 minute wet time and confirmed she was not aware it was required.


6) Failing to ensure the infection control officer at Offsite A conducted surveillance of hand hygiene and use of PPE:
Review of the "Isolation Precautions Surveillance Tool" and the "Hand Hygiene Surveillance Tool" for July 2015 from Offsite A revealed no documented evidence that surveillance was conducted by S3ADON/IC.

In an interview on 07/21/15 at 5:34 p.m., S3ADON/IC indicated she delegates the surveillance of hand hygiene and isolation precautions to staff nurses. She could offer no explanation for the surveillance revealing 100% (per cent) compliance when numerous observations were made of breaches in both isolation precautions and hand hygiene.


30172

Surveyor: Fremin, Wendy
Based on record reviews and interviews, the hospital failed to ensure the discharge planning evaluation included an evaluation of the likelihood of the patient's capacity for self-care or of the possibility of the patient being cared for in the environment from which he/she entered the hospital for 5 of 5 (#1-#5) patient records reviewed for discharge planning from a total of 7 (#1 - #7) sampled patient records.
Findings:

Review of the hospital policy titled, Discharge Planning, policy number 11-5.0.0, revised date of 06/01/14, revealed in part the following: A discharge plan will be developed for every inpatient within 3 days of admission. The case manager, along with the interdisciplinary team, will evaluate each inpatient and assess the following: the patient's functional and cognitive ability; the type of post-hospital care the patient will require and whether such care will (as written) the services of health care professionals or facilities; the availability of the required post-hospital services; and the availability and capability of a caregiver to provide the follow-up care in the home.


Patient #1
Review of the medical record for Patient #1 revealed the patient was a 74 year old male admitted on 06/18/15 to Offsite B with diagnoses of Respiratory Failure, Pulmonary Edema, Status Post Tracheostomy Placement and Left Carotid Endarterectomy. The patient was discharged on 07/14/15.

Review of Patient #1's "Resource Management Initial Assessment" conducted on 06/19/15 at 7:30 a.m. by S15CM (case manager) revealed Patient #1 lived with a spouse/significant other. There was no documented evidence of an assessment of the patient's capacity for self-care or, alternatively, to be cared for by others in the environment from which the patient was admitted from. There was no documented evidence of the patient's prior level of independence or ability to perform ADLs (activities of daily living). The assessment of the patient's need for medical equipment and supplies was marked not applicable, when the patient was admitted with a tracheostomy and wound care. There was no documented assessment of whether or not the patient would require home and/or physical environmental modifications. Review of the Insurance Information section revealed only the name and number of the insurance policies, and no documentation how the insurance coverage may or may not provide post-hospitalization services. Review of the assessment revealed the Discharge Plans were for the patient to return home with home health services.

Review of Patient #1's "Interdisciplinary Team Conference" documented on 06/23/15 and 06/30/15 at 10:00 a.m. revealed the Discharge Planning section was left blank. Review of the Interdisciplinary Team Conference documented on 07/07/15 at 10:00 a.m. revealed Wound Management was checked as a barrier to discharge and the discharge plan was Home with Home Health.


In an interview on 07/21/15 at 4:30 p.m. S12ADON/IC (Assistant Director of Nursing/Infection Control at Offsite B) reviewed the medical record for Patient #1 and confirmed the Resource Management Initial Assessment was the discharge evaluation and it did not contain documentation of an assessment of the patient's capacity for self-care or, alternatively, to be cared for by others in the environment from which the patient was admitted from. She confirmed there was no documentation of the patient's ability to perform his ADLs and stated this information was in the physical therapy evaluation. S12ADON/IC confirmed there was no assessment of whether or not the patient may require home or physical environment modifications. She confirmed the only assessment documented related to insurance coverage was a listing of the patient's insurance company and policy number. She confirmed the patient was admitted with tracheostomy and wound care and the initial discharge assessment indicated wound care supplies were not applicable. She confirmed the patient was discharged with wound care orders.


Patient #2
Review of Patient #2's medical record revealed she was an 84 year old female admitted on 07/13/15 to Offsite A with admit diagnoses of Dehydration, Hypernatremia, Urinary Tract Infection (UTI), Hydronephrosis, Renal Calculi, Retained Urinary Stent, and Neurogenic Bladder. She had a history of Diabetes Mellitus, Pulmonary Embolus, Deep Vein Thrombosis, Osteoarthritis, Glaucoma, Alzheimer's Disease, Hypothyroidism, Hypertension, and Hypokalemia. She was last admitted from 05/29/15 through 06/19/15.

Review of Patient #2's "Pre-Admission Patient Screening" conducted on 07/13/15 revealed she required maximum assistance to perform ADLs.

Review of Patient #2's "Resource Management Initial Assessment" conducted on 07/15/15 at 2:00 p.m. by S26CM revealed no documented evidence if Patient #2 lived alone, with a spouse or significant other, in the nursing home, in assistant living, or other location. Further review revealed her prior level of independence was documented as bedbound, turn every 2 hours, and wheelchair with maximum assistance. Her discharge plan was documented as "daughter undecided."

Review of Patient #2's "Resource Management Progress Notes" revealed an entry on 07/15/15 at 2:00 p.m. by S26CM that the initial resource management assessment was completed "briefly (with) pt.'s (patient's) daughter."

Review of Patient #2's "Interdisciplinary Team Conference" documented on 07/15/15 at 9:00 a.m. revealed the expected discharge date was "pending", no documented evidence if the patient lived alone or with others, the discharge plan was return home with home health, the barriers to discharge were safety awareness, medical status, and wound management, and there was no documented evidence of discharge needs.

Review of Patient #2's entire medical record, including nursing notes from admit through 07/21/15, revealed no documented evidence that Patient #2's discharge planning evaluation included an evaluation of whether her post discharge needs could be met in the environment from which she entered the hospital, an assessment of whether Patient #2 or her support person had the ability to perform ADLs, and an assessment of whether home or physical environment modifications were needed, and if so could be made, to safely discharge Patient #2 to her original setting.

In an interview on 07/21/15 at 5:34 p.m., S3ADON/IC confirmed Patient #2's discharge plan was not complete. She also confirmed the initial evaluation did not include an assessment of whether her post discharge needs could be met in the home and if home modifications were needed (and could be performed if needed) for her to return safely to her home.


Patient #3
Review of Patient #3's medical record revealed the patient was a 44 year old female admitted on 06/05/15 to the main campus with admit diagnoses of Acute Pancreatitis, Severe Malnutrition, and a new diagnosis of Diabetes Mellitus. The patient was discharged to home on 06/17/15.

Review of Patient #3's "Resource Management Initial Assessment" conducted on 06/05/15 at 4:50 p.m. by S27CM revealed Patient #3 lived with a 17 year old daughter. There was no documented evidence of an assessment of the patient's capacity for self-care or, alternatively, to be cared for by others in the environment from which the patient was admitted from. The assessment of the patient's need for medical equipment and supplies indicated a glucometer was needed. There was no documented assessment of whether or not the patient would require home and/or physical environmental modifications. Review of the Insurance Information section revealed only the name of the insurance policy, and no documentation how the insurance coverage may or may not provide post-hospitalization services. Review of the assessment revealed the Discharge Plans were for the patient to return home.

Review of the Interdisciplinary Team Conference documented on 06/11/15 at 2:00 p.m. revealed the discharge plan was Home with Home Health.

In an interview on 07/22/15 at 2:55 p.m. S27CM confirmed there was no documentation of an assessment of the patient's or the caregiver's ability to provide self-care at home. She stated she asked patients about any equipment they need and confirmed she does not document an assessment of whether or not home modifications are needed. S27CM stated she did not assess insurance coverage of post-hospital services. S27CM confirmed she had assessed the patient's need for a glucometer on the initial discharge assessment. S27CM stated the patient was given a prescription for the glucometer upon hospital discharge.


Patient #4
Review of Patient #4's medical record revealed the patient was a 75 year old female admitted on 05/07/15 to the main campus with admit diagnoses of Right Middle Cerebral Artery Non-hemorrhagic Infarct with Hemorrhagic Conversion (Stroke), Severe Protein Calorie Malnutrition, and Urinary Tract Infection with E.Coli. The record revealed the patient was admitted from a skilled nursing facility (SNF) and was discharged to another SNF on 06/05/15.

Review of Patient #4's "Resource Management Initial Assessment" conducted on 05/08/15 by S28CM revealed Patient #4 lived in a SNF and the patient's diagnosis was CVA (Stroke). There was no documented evidence of an assessment of the SNF's ability to provide the necessary post-hospital services to the patient. The assessment of the patient's need for medical equipment and supplies was left blank. Review of the initial discharge assessment revealed the Discharge Plans were for the patient to return to a SNF.

In an interview on 07/23/15 at 11:15 a.m., S28CM confirmed he had conducted the initial discharge assessment and indicated he only assessed that the patient came from and SNF and was going to another SNF as requested by the patient's daughter. He confirmed he did not document what the patient's discharge needs were. He confirmed he did not document the patient's need for medical equipment or supplies. S28CM stated the SNF will supply what the patient needs.



Patient #5
Review of Patient #5's medical record revealed the patient was an 88 year old male admitted on 05/08/15 to the main campus with admit diagnoses of Recalcitrant C-difficile with Colitis and Sacral Wound Secondary to Diarrhea. The record revealed the patient was admitted from a skilled nursing facility (SNF) and was discharged to another SNF on 06/26/15.

Review of Patient #5's "Resource Management Initial Assessment" conducted on 05/11/15 at 3:50 p.m. by S28CM revealed Patient #4 lived in a SNF and the patient's diagnosis was Unstageable Sacrum Wound. There was no documented evidence of an assessment of the SNF's ability to provide the necessary post-hospital services to the patient. There was no documented evidence of the patient's prior level of independence or ability to perform ADLs. The assessment of the patient's need for medical equipment and supplies was left blank. Review of the initial discharge assessment revealed the Discharge Plans were for the patient to return to the SNF.

In an interview on 07/23/15 at 11:15 a.m., S28CM confirmed he had conducted the initial discharge assessment and indicated he only assessed that the patient came from and SNF and was going back. S28CM indicated the SNF informs the hospital if they cannot meet the patient's needs. He confirmed he did not document what the patient's discharge needs were. He confirmed he did not document an assessment of the patient's ability to perform ADLs, or the patient's need for medical equipment or supplies. S28CM stated the SNF will supply what the patient needs.




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Based on record review and staff interview, the hospital failed to ensure the QAPI program reassessed the effectiveness of its discharge planning process as evidenced by failing to include quality indicators that monitored and evaluated the discharge planning process. Findings:

Review of the hospital's quality indicators provided by S13Quality Officer revealed the discharge planning quality indicators were monitored and tracked for the following indicators: Discharge destination coded correctly, Validation of admission form compliance, Important message from Medicare compliance, Follow-up copy of initial message compliance, and Valid order for DNR (Do Not Resuscitate).

In an interview on 07/22/15 at 9:50 a.m., S13Quality Officer confirmed the above indicators were the only indicators being monitored for discharge planning. When asked if readmissions were tracked, he provided a report titled, Utilization Management Function Report that included the numbers readmissions. He was unable to provide documentation of quality indicators related to the evaluation of the discharge planning process.

In an interview on 07/22/15 at 10:15 a.m. S2DON/IC (Director of Nursing/Infection Control at main campus) provided a form titled Peer Review Tool and stated utilization management used this form to review readmissions. S2DON/IC stated the chart review for readmissions was done after the patient was discharged. S2DON/IC stated problems identified would be reported to QAPI and indicated no problems had been identified with readmissions. Review of the Peer Review Tool revealed the only indicator related to the discharge planning process was the following: "Was the physician's discharge plan/follow-up care adequate on the first LTAC (Long Term Acute Care) stay? - Yes/No/NA"

In an interview on 07/23/15 at 10:20 a.m., S2DON/IC and S1ADM (Administrator) confirmed there was no hospital policy regarding reassessment of the discharge planning process and there was no methodology for conducting the Peer Review Tool. S2DON/IC stated she conducts the utilization review audits and confirmed there is no documentation or guide for what to review for discharge planning. S2DON/IC stated utilization management reviews 100% of readmissions and confirmed there was no review process of discharge planning for discharges that were not readmitted. S2DON/IC confirmed there was no QAPI monitoring of the discharge planning process.

Based on interview, the hospital failed to ensure the hospital-wide quality assessment and performance improvement (QAPI) program addressed problems identified by the infection control officer and developed and implemented corrective action hospital-wide as evidenced by developing and implementing corrective action at the individual hospital campus that scored below the targeted goal rather than hospital-wide.

In an interview on 07/22/15 at 9:30 a.m., S1ADM indicated the quality indicator data and required action plans, including those for infection control, are developed for each respective hospital campus when the quality indicator is below the targeted goal and not developed and implemented hospital-wide. He further indicated the QAPI (quality assessment and performance improvement) data is collected and reported individually for each campus and is not aggregated as a hospital total until the annual review is done.