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Based on record review and interview, the facility failed to evaluate contracted services for safety and effectiveness via its Quality Assurance Performance Improvement (QAPI) program.
Findings include:
Review of the facility document titled, "ETMC Specialty Hospital 2012 Performance Improvement Plan," revealed the following:
"The facility is a 36 bed hospital within a hospital located on the 4th and 5th floors of host hospital. Services that impact processes that affect patient care outcomes, directly or indirectly, are included in the Performance Improvement Process. Such services and groups include, but are not limited to the following: Patient and Professional Services- Nursing, Case Mgmt/Social Services, Pharmacy, Nutrition, Rehabilitation Therapies, Medical Staff, Cardiopulmonary Services, wound care. Support Services- Admitting, Finance/Accounting, Performance Improvement, Housekeeping, Referral Services, Medical Records, Staff/Patient Education, Risk Management, Infection Control/Employee Health. Contract Services- Laboratory, Radiology, Emergency Response, Chaplain Services, Anesthesia, Surgery, Dialysis, Orthotics/Prosthetics. Contract Support Services- Laundry, Food Services, Human Resources, Information Technology, Marketing, Materials Management, Security/Safety Officer, Plant Services, Biomedical Services."

Review of the QAPI minutes and data revealed that the following contracted services and contracted support services were not being evaluated by the facility QAPI process:
Laboratory, Radiology, Emergency Response, Chaplain Services, Anesthesia, Surgery, Dialysis, Orthotics/Prosthetics, Laundry, Food Services, Human Resources, Information Technology, Marketing, Materials Management, Security/Safety Officer, Plant Services, Biomedical Services.

During an interview on 12/17/12 at 1:20pm in the conference room, staff #4 confirmed that the contracted services were not being evaluated by the facility QAPI process.

Based on observations, record reviews, and interviews conducted 12/17/2012 thru 12/18/2012, the facility failed to provide a safe and sanitary environment to prevent infections on 2 of 2 floors (400 and 500). This deficient practice has the potential to adversely impact the health and safety of all patients receiving care at the facility.

Findings included:
1. During observations of the pharmacy on 12/17/2012 at 9:15 a.m. the following were found:
*One (1) box of the antibiotic agent Zyvox was stored on the floor.
*Seven (7) boxes of 0.9 percent NaCl (sodium chloride) intravenous fluid were stored on the floor.
*Two (2)boxes of 15 percent Clinisol amino acid were stored on the shelf in the shipping boxes.
* Eight (8) boxes of 25 percent Dianeal peritoneal dialysis solution were stored in the shipping boxes above bags of the same dialysis solution.
*Two (2) boxes of 4.2 percent Sodium Bicarb injections were stored on the shelf in shipping boxes.
*Two (2) boxes of 0.99 percent NaCl were stored on the floor.
*One (1) box of sterile vials and injectors was stored on the shelf in shipping boxes.

During an interview on 12/17/12 at 10:00 a.m., in the pharmacy, Staff #18 confirmed the observations and reported he had removed the intravenous fluids from the floor because they were not supposed to be stored there.


2. During observation rounds of patient care areas on floors 4 and 5 on 12/17/2012, the following observations were made:
* At 9:20 a.m.,isolation carts were stored in the hallway outside of patient rooms on the 5th floor. The isolation carts were in use for patients with isolation precautions. Five (5) of seven (7) isolation carts had water pitchers stored on top.

During an interview on 12/17/12 at 1:45 p.m., Staff #4 reported, these "outside" pitchers were used to obtain ice from the ice machine near the nurses' station. The "outside" pitchers were then taken into the patient's room and used to fill another water pitcher. Then the "outside" pitchers, now potentially contaminated, were returned to the isolation cart in the hallway.

* At 10:00 a.m., there was an extra large hospital chair in the hallway. Model #855110J0002. It had a build- up of dust and dirt.

* At 10:00 am, the wall directly behind the sink in the patient hallway on the 5th floor, behind the staff hand washing sink near the nurses station was stained and dirty. Floors around the sink had a build-up of dirt and dust.

* At 10:10 am, the patient shower area on the 5th floor was dirty and had a strong odor of mildew. The vent in the shower room had a build-up of dust and dirt and was clogged with debris. The shower curtain was soiled with dirt and stained. The floor had dirt and debris built up in the corners.

* At 10:30 am, on the 5th floor 3 of 3 Dynamaps used for patient vital signs had a build-up of dust and dirt. Serial #33069, #37986, and #33071.

* At 10:45 am, on the 5th floor 3 of 3 portable blood pressure rolling carts used to obtain patient blood pressures had a build-up of dust and dirt.

* At 10:50 am, on the 5th floor in room 5513, the bathroom air vent had a build-up of dust and dirt. The bathroom floor had a build-up of dust and dirt with debris built up in the corners.

* At 1:02 pm, on the 5th floor in room 5518, an intravenous pump being used to provide fluids to a patient had a build-up of dust and dirt.

* At 11:00 am, on the 4th floor, 1 of 1 rolling blood pressure cuffs had a build- up of dirt and dust.

* At 11:10 am, on the 4th floor, 3 of 3 isolation carts had a build-up of dust and dirt.

* At 11:20 am, on the 4th floor in room 4413, the bathroom floor had a build-up of dust and dirt and had debris built up in the corners.

*During an observation on 12/17/12 at 12:50 p.m., Patient #15 had a tracheotomy and was receiving a tube feeding per infusion pump. The base of the infusion pump pole had a build-up of dried off-white substance. Also, an unbagged ambu bag was laying on the oxygen flow meters on the wall. Two (2) unbagged wash basins identified as belonging to Patient #15 were stored on the floor underneath the sink, and two (2) unbagged bed pans were stored on the floor in the bathroom.

Review of the facility "Policy #N1005 Subject: Infection Control" Last Revision: June 2006 revealed the following:

General Information: Effective infection control begins with and relies on the practice of good health habits and patient care practices by each employee to provide a safe, sanitary and convertible environment that inhibits and/or prevents the development and transmission of disease and infection.

1. Patient Care Practices
a. Standard/Transmission-Based Precautions will be employed by all employees when providing patient care. (See infection control manual)
b. To prevent exposure to Blood/Body substances (BBS) appropriate Personal Protective Equipment (PPE) will be initiated as each individual situation dictates.

6. Routine Cleaning
a. Housekeeping will perform the daily routine cleaning, i.e., restrooms, floors, surfaces, ect.
b. Medication refrigerators will be cleaned weekly.

7. Cleaning of Equipment
a. All Equipment exposed to Blood/Body Substances (BBS) will be cleaned with soap and water immediately after patient use and disinfected.
b. Instruments which require decontamination will be cleaned with soap and water and sent to ETMC-Tyler Sterile processing department for sterilization.
c. Wheelchairs and oxygen canisters, will be cleaned with an approved disinfectant after patient discharge.
d. Wheeled shower chair seats will be cleaned with the appropriate disinfectant after each patient use.
e. Bedside commode chairs are cleaned after patient discharge by housekeeping staff.
f. The outside of the Accu-Check monitor will be cleaned with a soft cloth slightly dampened with warm, soapy water as needed.


During an interview on 12/18/2012 at 1:30 pm, staff #29 confirmed these observations. Staff #29 reported the facility would take measures to properly clean the equipment, notify housekeeping of the areas that appeared unclean, and institute another method to get ice for the patients, so the water pitchers would not be taken into a patient room and then returned to the isolation cart for further use.

Based on record review and interview, the governing body failed to require contracted services to be evaluated for safety and effectiveness by the facility's Quality Assurance Performance Improvement (QAPI) program.


Findings include:

Review of the facility document titled, "ETMC Specialty Hospital 2012 Performance Improvement Plan," revealed the following:
"The facility is a 36 bed hospital within a hospital located on the 4th and 5th floors of host hospital. Services that impact processes that affect patient care outcomes, directly or indirectly, are included in the Performance Improvement Process. Such services and groups include, but are not limited to the following: Patient and Professional Services- Nursing, Case Mgmt/Social Services, Pharmacy, Nutrition, Rehabilitation Therapies, Medical Staff, Cardiopulmonary Services, wound care. Support Services- Admitting, Finance/Accounting, Performance Improvement, Housekeeping, Referral Services, Medical Records, Staff/Patient Education, Risk Management, Infection Control/Employee Health. Contract Services- Laboratory, Radiology, Emergency Response, Chaplain Services, Anesthesia, Surgery, Dialysis, Orthotics/Prosthetics. Contract Support Services- Laundry, Food Services, Human Resources, Information Technology, Marketing, Materials Management, Security/Safety Officer, Plant Services, Biomedical Services."

Further review of the facility document titled, "ETMC Specialty Hospital 2012 Performance Improvement Plan," revealed the following:
"The Board of Directors had the ultimate responsibility to ensure that a planned, systematic, organization-wide approach to process design, performance measurement, analysis and improvement is established."

Review of the QAPI minutes and data revealed that the following contracted services and contracted support services were not being evaluated by the facility QAPI process:
Laboratory, Radiology, Emergency Response, Chaplain Services, Anesthesia, Surgery, Dialysis, Orthotics/Prosthetics, Laundry, Food Services, Human Resources, Information Technology, Marketing, Materials Management, Security/Safety Officer, Plant Services, Biomedical Services.

During an interview on 12/17/12 at 1:20pm in the conference room, staff #4 confirmed that the contracted services were not being evaluated by the facility QAPI process.

Based on record review and interview, the facility failed to assure current patient history and physicals (H&P) were documented and on the chart within 24 hours. 4 of 14 (#4, 6, 7, and 14) charts had history and physicals that were not documented and on the chart within 24 hours.

Findings include:

Review of facility policy titled, "History and Physical Reports," revealed the following: "The Admitting Physician shall be responsible for completing a History and Physical within twenty-four (24) hours of each patient's admission to the facility or within five days prior to admission."

Review of the Medical Staff Rules and Regulations revealed the following: "A complete history and physical examination shall be completed by an appropriately privileged Physician Staff Member no more than seven (7) days before or within twenty-four (24) hours after admission."

Review of patient records revealed the following H&Ps transcribed more than 24 hours after the patient was admitted, therefore not on the chart within 24 hours:
-Patient #4 was admitted on 12/11/12 with H&P transcribed on 12/14/12
-Patient #6 was admitted on 10/26/12 with H&P transcribed on 10/29/12
-Patient #7 was admitted on 12/06/12 with H&P transcribed on 12/08/12
-Patient #14 was admitted on 11/21/12 with H&P transcribed on 11/24/12

Further, no chart had a H&P completed within 7 days before admission.

During an interview on 12/18/12 at 2:00pm in the 5th floor nursing station, staff #3 confirmed these findings for charts #4, 6, and 7.

During an interview on 12/18/12 at 1:30pm in the 4th floor nursing station, staff #1 confirmed the finding for chart #14.

Based on record review and interview, the facility failed to assure initial patient skin integrity assessments could not be altered without the author's knowledge. 5 of 14 (#2, 4, 8, 10, and 12) initial skin assessments were written/drawn in pencil, allowing any staff with access to alter the document without the author ' s knowledge.

Findings include:

Review of patient charts revealed 5 (#2, 4, 8, 10, and 12) initial skin assessments written/drawn in pencil, allowing any staff with access to alter the document without the author's knowledge.

During an interview on 12/18/12 at 2:00pm in the 5th floor nursing station, staff #3 confirmed these findings.

Based on record review and interview, the facility failed to assure medical record entries had appropriate dates, times and signatures. 7 of 14 (#4, 6, 8, 10, 11, 12, and 13) charts had consent forms that were not signed by the physician. 11 of 14 (#1, 2, 3, 4, 5, 7, 8, 9, 11, 12, and 13) charts had progress notes lacking dates and/or times.

Findings include:

Review of patient charts revealed the following with consents not signed by the physician:
-Chart #4 with 4 unsigned consents
-Chart #6 with 3 unsigned consents
-Chart #8 with 1 unsigned consents
-Chart #10 with 2 unsigned consents
-Chart #11 with 3 unsigned consents
-Chart #12 with 2 unsigned consents
-Chart #13 with 2 unsigned consents

During an interview on 12/18/12 at 2:00pm in the 5th floor nursing station, staff #3 confirmed these findings for charts #4, 6, 8, 10, 11 and 12.

During an interview on 12/18/12 at 1:30pm in the 4th floor nursing station, staff #1 confirmed the finding for chart #13.

Review of patient charts revealed the following with progress notes lacking dates and/or time:
-Chart #1 with no time on progress notes x2
-Chart #2 with no time on progress notes x4
-Chart #3 with no time on progress notes x2
-Chart #4 with no time on progress notes x6
-Chart #5 with no time on progress notes x3
-Chart #7 with no time on progress notes x2
-Chart #8 with no time on progress notes x2
-Chart #9 with no time on progress notes x1
-Chart #11 with no time on progress notes x1 and no date and time on progress note x3
-Chart #12 with no time on progress notes x4
-Chart #13 with no time on progress notes x9

During an interview on 12/18/12 at 2:00pm in the 5th floor nursing station, staff #3 confirmed these findings for charts #1, 2, 3, 4, 5, 7, 8, 9, 11, and 12.

During an interview on 12/18/12 at 1:30pm in the 4th floor nursing station, staff #1 confirmed the finding for chart #13.

Based on record review, the facility also failed to assure written orders were timed in 6 of 14 charts (#1, 4, 5, 6, 7, and 8).

Findings include:

A review of patient charts revealed the following times missing on physician orders (Chart # x number of missing times in the chart):
-Chart #1 x 4
-Chart #4 x 4
-Chart #5 x 2
-Chart #6 x 3
-Chart #7 x 3
-Chart #8 x 3

During an interview on 12/18/12 at 2:00pm in the 5th floor nursing station, staff #3 confirmed these findings.

Based on record review, the facility failed to assure verbal orders were authenticated by the ordering physician within 48 hours in 6 of 14 charts (#1, 4, 6, 8, 13, and 14).

Findings include:

Review of facility policy #A1080, "Verbal and/or Telephone Orders, Guidelines for Utilizing" revealed the following: "Verbal orders are to be authenticated 48 hours of when the order was given."

Review of medical records revealed 6 charts where the verbal orders had not been countersigned within 48 hours. Findings were as follows (Chart# x number of verbal orders without countersignature):
-Chart #1 x 1
-Chart #4 x 2
-Chart #6 x 1
-Chart #8 x 1
-Chart #13 x 6
-Chart #14 x 6

During an interview on 12/18/12 at 2:00pm in the 5th floor nursing station, staff #3 confirmed these findings for charts #1, 4, 5, 6, and 8.

During an interview on 12/18/12 at 1:30pm in the 4th floor nursing station, staff #1 confirmed the findings for charts #13 and 14.

Based on record review and interview, the facility failed to assure current patient history and physicals (H&P) were documented and on the chart within 24 hours. 4 of 14 (#4, 6, 7, and 14) charts had history and physicals that were not documented and on the chart within 24 hours.

Findings include:

Review of facility policy titled, "History and Physical Reports," revealed the following: "The Admitting Physician shall be responsible for completing a History and Physical within twenty-four (24) hours of each patient's admission to the facility or within five days prior to admission."

Review of the Medical Staff Rules and Regulations revealed the following: "A complete history and physical examination shall be completed by an appropriately privileged Physician Staff Member no more than seven (7) days before or within twenty-four (24) hours after admission."

Review of patient records revealed the following H&Ps transcribed more than 24 hours after the patient was admitted, therefore not on the chart within 24 hours:
-Patient #4 was admitted on 12/11/12 with H&P transcribed on 12/14/12
-Patient #6 was admitted on 10/26/12 with H&P transcribed on 10/29/12
-Patient #7 was admitted on 12/06/12 with H&P transcribed on 12/08/12
-Patient #14 was admitted on 11/21/12 with H&P transcribed on 11/24/12

Further, no chart had a H&P completed within 7 days before admission.

During an interview on 12/18/12 at 2:00pm in the 5th floor nursing station, staff #3 confirmed these findings for charts #4, 6, and 7.

During an interview on 12/18/12 at 1:30pm in the 4th floor nursing station, staff #1 confirmed the finding for chart #14.

Based on record review and interview, the facility failed to assure consent forms were properly executed and complete with the signature of the physician. 7 of 14 (#4, 6, 8, 10, 11, 12, and 13) charts had consent forms that were not signed by the physician.

Findings include:

Review of patient charts revealed the following with consents not signed by the physician:
-Chart #4 with 4 unsigned consents
-Chart #6 with 3 unsigned consents
-Chart #8 with 1 unsigned consents
-Chart #10 with 2 unsigned consents
-Chart #11 with 3 unsigned consents
-Chart #12 with 2 unsigned consents
-Chart #13 with 2 unsigned consents

During an interview on 12/18/12 at 2:00pm in the 5th floor nursing station, staff #3 confirmed these findings for charts #4, 6, 8, 10, 11 and 12.

During an interview on 12/18/12 at 1:30pm in the 4th floor nursing station, staff #1 confirmed the finding for chart #13.

Based on observation, interview and record review the facility failed to ensure out dated medications were discarded on 1 of 2 crash carts on Floor 400 (emergency treatment room).


During an observation on 12/17/12 at 1:30 p.m., the following out dated medications were found on the crash cart in the emergency treatment room:

*Two (2) boxes of 10 percent Calcium chloride injections expired 12/1/2012;
*Three (3) boxes of Atropine 1 milligrams expired 11/2012;
*Two (2) bottles of Magnesium sulfate expired 11/2011;
* Four (4) bottles of Vassopressin expired 09/2011.

During an interview on 12/17/12 at 1:30 p.m., Staff #3 confirmed the medications were expired.

Review of the "Adult Crash Cart Checklist" revealed the expiration dates on the medications were supposed to be checked on Wednesday 12/05/2012. There was no documention on the form that the medications were checked.

Review of the facility "Durg Storage and Monitoring" policy dated 08/2012 revealed: "Crash carts will be checked for integrity of drug supply and out dated drugs will be removed and restocked on an ongoing basis in addition to the monthly checks".

Based on record review and interview the facility failed to ensure the negative pressure isolation rooms (Rooms #5512 and #4419) were properly monitored and maintained to ensure proper operation. This deficient practice has the potential to adversely impact the health and safety of all patients receiving care at the facility.

During tour of the facility on 12/17/2012, staff #4 advised that there were two negative pressure isolation rooms within the facility. They were rarely ever used and were unsure of how they were monitored or maintained.

During an interview on 12/18/2012, staff #29 reported that there were written policies in the Plant Sevices Department for monitoring the negative pressure rooms semi-annually and daily if patients were in those rooms requiring negative pressure isolation.

During an interview on 12/17/2012 staff #37 reported that unless the negative pressure isolation rooms were being used for negative pressure isolation, the rooms were not monitored. When and if they were used by a patient requiring negative pressure isolation, they would monitor daily.

Review of East Texas Medical Center (ETMC) Plant Services Department Policy and Procedure Manual on 12/17/2012 revealed the following:

"Subject: "Infection Control" Effective: 12/23/2008.
Ref: EC.02.05.EP4
Policy:
It is the policy of East Texas Medical Center, Tyler, to consistently strive to reduce the potential for hospital-acquired illnesses. This will be accomplished through a proactive approach of preventative maintenance, engineering controls, inspections and testing of the equipment and resources associated with the mechanical and electrical systems serving these areas that may be a possible source of a hospital acquired illness. The Plant Services Department will work in conjunction with Infection Control and nursing departments in order to accomplish these tasks.
Procedure:
The preventative maintenance, engineering controls, inspections and testing of this equipment shall be inclusive of but not limited to the utility systems serving the areas in the medical center that treat:
*Infectious diseases requiring special isolation ventilation systems
*Areas requiring reverse isolation ventilation systems
*Exhaust ventilation systems serving areas that utilize hazardous materials, hazardous gases or chemicals (i.e.,ethylene oxide, formaldehyde, Gluteraldehyde, Metracide, Formalyne, Xylene, ect.)
*Construction and maintenance sites that may produce dust that could migrate into ventilation systems serving the medical center or patient care areas.
These systems shall be maintained and tested for proper operation and effectiveness not less that semi annually, as determined by the original design criteria, or subsequent re-design initiatives performed by qualified individuals or firms. Increased testing and inspections of systems may occur due to the outcome of inspection or testing.
In the event of a positive test result or the discovery of a system that is not functioning properly the infection control department and the affected area(s) or department(s) will be notified immediately.
Documentation:
All maintenance, testing, inspections, and laboratory analysis records will be maintained in the Plant Services Department.
In the event of a positive test result or the discovery of a system that is not functioning properly, the plan of action designed to remedy the problem or result will be documented, as will the test results that enable the system or area to be placed back into service."
Interview on 12/17/2012, with staff #4, confirmed that the maintenance and monitoring of the negative pressure isolation rooms was left up to the plant services department.