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The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See A-709.

Based on observation, interview and record review the facility failed to provide an active program for the prevention and control of healthcare associated infections resulting in the increased risk for acquisition of a healthcare associated infection for all patients that are served by the facility. See specific tags below (A-747 and A-749) for details. Findings include:

On 12/6/11 during a review of the Infection Control data for device associated infections it was revealed that the rate for central line-associated bloodstream infection (CLABSI) in 2010, was 2.46 CLABSIs per 1000 catheter days. In 2011 the CLABSI rate ranged from a high of 8.61 in June to a low of 2.13 in February with an average rate of 5.18 CLABSI per 1000 catheter days which represents and increase from 2010.
A review of documents revealing outcome indicators for healthcare onset for multi-drug resistant organisms (MDRO) shows that acquisition of clostridium difficile, methicillin resistant staphylococcus aureus (MRSA) and multi-drug resistant Acinetobacter (MDR-Acinetobacter) had increased from 2010 rates respectively as follows: 17.6 from 11.5 (C. Diff.), 0.61 from 0.43 (MRSA), MDR Acinetobacter 0.31 from 0.29. A review of the Infection Control Committee minutes for 2011 reveals that the committee met in January 2011 and again in September 2011. Interview with staff J confirms that in the absence of an infection preventionist the committee did not meet routinely for the purpose of analysis and intervention to reduce the above mentioned healthcare associated infections. Staff E indicated that an Infection Control Committee meeting was scheduled for the day of this Infection Control Interview (12/7/11) however was rescheduled.
Interview with staff E reveals that she had just started in her position in May 2011. According to staff J the position for Infection Preventionist was "difficult to fill". Additionally healthcare associated infection surveillance in late 2010 and 2011 was "conducted retrospectively". Opportunity for taking action to reduce healthcare associated infections was not available until after the rates were calculated later in 2011.

Based on credentialing review and interview the facility failed to grant privileges to 3 of 13 practitioners (#8, #9, #12) reviewed resulting in the potential for a practitioner to work out of their scope of practice possibly causing patient harm. Findings include:

On 12-6-2011 at approximately 1400 during review of medical staff credentialing it was revealed that practitioner #8, #9 and #12 did not have privileges granted to them. The form that was used to indicate requested privileges was filled out, however, no signature indicating approval was on the form.

On 12-6-2011 at approximately 1400 during an interview with staff H it was confirmed that no approval had been granted for the three practitioners.

On 12-5-11 at approximately 1115 during review of the medical record for patient #1 who was admitted for pain management and respiratory management, it was revealed that pain was assessed at a 9 out of 10 on 12/5 and no medication or intervention was given and or documented. This finding was confirmed with staff C at approximately 1115.

On 12-7-2011 at approximately 1015 during review of the medical record for patient #32 who was admitted for osteomyelitis, pain management and respiratory insufficiency, it was revealed that pain was assessed on 12/5/2011 at 1946 at a level of 9 out of 10, no medication or intervention was given or documented. No follow up on the pain level was documented. This finding was confirmed with staff K.

On 12-7-2011 at approximately 1045 during review of the medical record for patient #33 who was admitted for wound care (for 9 wounds), respiratory failure and rehabilitation, it was revealed that the patient had a pain level of a 5 out of 10 on 8-6-2011 at 0800, no medication or intervention was given or documented. No follow up on the pain level was documented. On 12-1-2011 at 1700 wound care was missed and no documentation was revealed as to why a patient with extensive wounds would miss wound care. These finding was confirmed with staff K who stated "They are just too busy sometimes to document, but we do expect that it be documented."


29955

Based on medical record review, policy review, and interview the facility failed to ensure patients were turned as ordered, patient assessments were documented in the electronic medical record, and calorie counts were initiated as ordered resulting in the potential of pressure wounds or extending damage of existing wounds, not meeting the nutritional needs of patients, and failure of patient data being current and easily accessible for all patient providers. Findings include:

On 12/5/2011 at approximately 1020 patient #18 was observed in a left side lying position. During an interview with staff #V it was indicated that all patients were to be turned every 2 hours as per protocol. A review of the patient's medical record indicated an order for the patient to be turned every 2 hours. At 1245 patient #18 was observed again to be in a left side lying position. Documentation indicated the patient had been turned to their right side in the electronic medical chart. At 1515 the patient remained in the same left lying position. Staff #V was questioned if the patient had been turned as ordered. Staff #V indicated the patient had not been turned or repositioned as ordered. The patient (#18) was incapacitated and ventilated. The patient did not have the ability to move independently and had a documented pressure sore with orders from the physician turning was essential to prevent further skin insult.

According to the policy titled "Guidelines for Nursing Care" page 2, subpart activity and mobility, "Bedfast patient turned and documented - every 2 hours". Staff #V confirmed the patient had not been turned as ordered or by policy.

On 12/7/2011 at approximately 1045 during medical record review, it was revealed that patient #36 had not had a calorie count initiated as ordered. The order read for the calorie count to start on 11/26/2011 and end on 11/28/2011. Although the order had been noted in the chart, no documentation could be provided by staff #M or found in the dietary notes or nursing notes indicating the calorie count had been conducted. Staff #M confirmed the calorie count had not taken place as ordered.

On 12/5/2011 at approximately 1530 during a review of medical records, it was revealed the nursing assessment had not been charted for 2 of 3 patients (#18 and #19). Staff #W was queried as to why the patients physical assessments had not been documented and she stated "I have not had time to get to them yet". Staff #B was asked if there was a expected timeliness for assessments to be charted and she stated "we expect assessments to be documented and available by 1200".

On 12/6/2011 at approximately 1548 an interview was conducted with patient #49's family member. The family member stated her family member had been left sitting in a chair for over 7 hours. The family member stated that when patient #49 was moved out of the chair it was found that the patient had been incontinent and been sitting in stool for a period long enough that the stool had permeated the pad the patient was seated. The family member stated the staff were sent home quite often leaving only 2 patient care technicians on the floor to assist patients.

Based on medical record review, policy review, and interview the facility failed to ensure the nursing care plan was reviewed and updated by the staff nurse in 24 of 26 patients resulting in inaccurate nursing interventions resulting in the potential to fail to meet patient goals and outcomes.

On 12/7/2011 at approximately 1040 during medical record review, it was revealed the facility failed to keep a current nursing care plan for 24 of 26 patients (#10,#11,#12,#13,#14,#15,#16,#17,#18,#19,#31,#32,#33,#34,#35,#36,#37,#38,#39,#40,#46,#47,#48, and #50). During a review of the medical record it was noted that staff #S had electronically signed 24 of 26 nursing care plans. Staff #K was asked if staff #S had been the staff nurse providing care for 24 of the 26 patients and if staff #S had the knowledge to support any updates to the nursing care plan. Staff #K stated staff #S was in a supervisory nursing position on 12/2/2011 during the time the nursing care plans were updated and would not have had sufficient information to change or update the individual nursing care plans. Staff #L agreed the nursing care plans would not have been able to have been updated by staff #S and it was impossible to update the information for 24 patients in a 15 minute time frame from 22:26 to 22:41.

According to the document titled "Vibra Hospital Southeastern Michigan 2010 -2011 Organizational Plan Delivery of Patient Care, Treatment, and Services" page 11, subpart registered nurse, states "The registered nurse is responsible for performing a complete assessment/reassessment of all the patients assigned and developing, reviewing or revising nursing care plans and formulating patient/family education plans". Staff #L was queried if it was customary for the nursing supervisor to update the nursing care plans of the patient instead of the nurse providing bedside care. Staff #L responded "no. It is the responsibility of the bedside nurse to address nursing care plans".

Based on medical record review and interview the facility failed to ensure that the registered nurses authenticated their orders for 2 of 9 patients (#31 and #33) resulting in the potential for failure to provide care. Findings include:

On 12-7-2011 at approximately 1015 during review of the medical record for patient #31 it was revealed that two orders were not signed by the registered nurse caring for the patient.

On 12-7-2011 at approximately 1100 during review of the medical record for patient #33 it was revealed that an order was not signed by the registered nurse caring for the patient.

On 12-7-2011 at approximately 1100 during an interview with staff K it was stated "We expect that a registered nurse (RN) signs off on the orders to ensure that the order is complete and carried out. The RN's are just so busy sometimes it gets missed."

Based on medical record review and interview the facility failed to ensure all orders are authenticated by physicians for 6 of 14 charts reviewed (#1, #2, #13, #17 #32, #33), resulting in the potential for medical errors. Findings include:

On 12-6-2011 at approximately 1000 during review of the policy titled Physician Orders-Verbal Or Telephone it was stated "All verbal orders shall be transcribed in the medical record and shall be countersigned by the practitioner the next time the prescribing practitioner provides care to the patient, assesses the patient or documents information in the patient's medical record, or within 48 hours, whichever is earlier."

On 12-5-2011 at approximately 1000 during review of the medical record for patient #1 it was revealed that an order was not signed and verified by a physician. This finding was confirmed with staff C.

On 12-5-2011 at approximately 1130 during review of the medical record for patient #2 it was revealed that two orders were not signed and verified by a physician. This finding was confirmed with staff C.

On 12-7-2011 at approximately 1030 during review of the medical record for patient #32 it was revealed that two orders were not signed and verified by a physician. This finding was confirmed with staff K.

On 12-7-2011 at approximately 1045 during review of the medical record for patient #33 it was revealed that two orders were not signed and verified by a physician. This finding was confirmed with staff K.


29774

On 12/5/11 at 1315 during record review for patient #17 revealed that three telephone orders taken;
a.) on 11/28/11 "Contact nephrology concerning low HBG 7.9"
b.) on 11/30/11 for "two units of PRBC"
c.) on 12/1/11 "change renagel to 2 tabs = 1600 mg and change procrit to 6000 units with each dialysis 3 x week"

The three above noted telephone orders were not signed by the physician as of 12/5/11. This was confirmed by staff B.

Based on medical record review and interview the facility failed to ensure the review of medical and pharmacy orders of patients every twelve hours in 5 of 5 patients (#18,#19,#32,#35, and #36) resulting in the potential to miss pertinent orders for patient care and miss inaccurate orders.

On 12/5/2011 at approximately 1040 during a review of medical records, it was revealed the chart had not been checked either on a 24 or 12 hour routine in 2 of 2 patients (#18 and #19). The chart lacked the initials of nursing staff to indicate the chart had been checked in both the paper chart and in the electronic medical record.

On 12/6/2011 at approximately 1620 during an interview with the Chief Clinical Officer, it was revealed that chart checks were to be conducted by the staff nurse during every shift during the nurse's 12 hour shift.

On 12/7/2011 at approximately 1000 during an interview with staff #T, it was revealed the nursing staff are instructed to conduct 24 hour chart checks but not all staff were practicing the chart checks.

On 12/7/2011 at approximately 1020 during medical record review, it was revealed chart checks had not been conducted on 3 of 3 patients (#32, #35, and #36). The findings were confirmed by staff #L that the charts did not indicate the review by nursing staff at either a 12 or 24 hour interval.

Based on record review and interview the facility failed to complete medical records within thirty days of the patient's discharge. Findings include:

During interview and document review in the Medical Records Department with staff A, D and H, on 12/06/11 at approximately 0900, it was found that the hospital had 20 delinquent medical records not completed within the thirty days of the patients being discharged. Staff H stated the records were missing Discharge Summaries. Staff D provided further clarification stating that some of these records just required physician signatures and other things.

Based on observation and interview the facility failed to ensure pharmaceuticals are stored appropriately and according to accepted professional principles resulting in the potential that pharmaceuticals will not provide optimal mechanisms of action. Findings include:

On 12/5/11 during a tour of the facility, the medication refrigerator located in the medication room on the High Observation Unit was observed to have a digital thermometer reading of 50 degrees Farenheit. According to the documentation of recorded temperatures the acceptable range was 37-47 degrees Farenheit. The range set on the temperature monitor was between 35-51 degrees Farenheit. This was confirmed by staff B. Interview with staff F reveals that responsibility for the monitoring of the refrigerator falls with the plant operations person. Interview with staff G confirms that the refrigerator was out of range however the audible alarms are always moved to the "no audible" alarm setting. Staff G stated that he does not set the refrigerator temperature however is called when the recorded temperature falls out of the "acceptable" range.

Based on observation, it was determined that the facility failed to ensure all areas were maintained to ensure an acceptable level of safety and quality. The findings include:

1. Air Handling Units (AHU) mainly units 7, 8, and 9 filters were noticed to be very dirty and may lead to improper air filtration and/or ventilation deficiency.

2. The high observation unit, room 581 on the fifth floor is lacking at least one handwashing sink to comply with minimum requirement. Lack of handwashing sink will not promote proper hand hygiene and could be a cause for contamination.

3. The drainage pipe for the double compartment prep sink in the kitchen area to the south side of the kitchen is improperly plumbed and the required air gap has not been met. The current non air gaped plumbing could lead to cross contamination of the food being prepared for serving to patients and staff.

4. The abandoned/no longer in use handwashing sink currently exists in the equipment storage room on the second floor (east side) next to the service elevators must be removed and all water lines and drainage be properly capped. Abandoned water lines can be a source for bacteria growth and could lead to contaminate the main water supply line for the facility.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors, the facility does not comply with the applicable provisions of the Life Safety Code.

See the K-tags on the CMS-2567 dated December 7, 2011 for Life Safety Code.

Based on observation and interview the facility failed to ensure an acceptable level of safety for healthcare workers and visitors who work or visit the High Observation Unit, while patients are being hemodialyzed, resulting in a significant risk for tripping and falling while walking in the unit in addition to impeding an emergent unit evacuation. Findings include:

On 12/5/11 at 10:45 during a tour of the High Observation Unit Patient #17 was being dialyzed using a portable R/O connected to the hand washing sink in the single shared patient designated bathroom. The hoses that connected the hemodialysis machine to the water supply of the hand hygiene sink snaked across the walkway that accesses the medication room, representing a trip hazard for people walking on the unit or accessing the medication room. Interview with Staff B confirms that the hemodialysis water hose represents a trip hazard.

Based on observation, interview and document review the facility failed to monitor and control infection control practices to minimize transmission of infectious agents for all patients served by the facility. Findings include:

On 12/5/11 during facility tour on the High Observation Unit at approximately 1045, found that in cubicle area #6 (patient #17) the patient was being dialyzed using portable R/O water attached to the hand hygiene sink in the single common-use patient bathroom. A single hand hygiene sink that was available for the four occupied cubicle area-beds, two of which were contact isolation, had an emptied intravenous bag contained in it along with a used coffee cup stored on the back rim of the sink and was not available for use. Interview with staff V confirms that the sink is not available for use with the emptied IV bag and used coffee cup storage around the sink. She indicated that she uses the hand gel for hand hygiene.

On 12/5/11 during facility tour on the High Observation Unit at approximately 1050 found a half-full tray of blue topped laboratory tubes with an expiration date of 9/2011 that were available for patient use, stored in a clean patient care storage cabinet. Interview with staff B on 12/5/11 at 1100 confirms that the blue topped lab tubes were outdated.

On 12/5/11 during facility tour on the High Observation Unit at approximately 1055 found labeled medication drawers used for cardiopulmonary medication for one drawer and wound care medication used for storage in a separate drawer, each of the six occupied beds had these drawers available in a clean storage cabinet. Inspection of these drawers revealed that the inside of these drawers were soiled and some contained dried reddish debris. During observations of care for Patient #18) by respiratory therapist staff V, found that the therapist used respiratory medication that had been laid on the patients chest was moved to the top of the storage cabinet, used for personal protective equipment storage, from which the therapist replaced it to the drawer in the storage cabinet without wiping it down. Patient #18 was in contact isolation, which was confirmed by staff #B. Continuing to watch the respiratory therapist, while gloved and gowned, observed her reaching behind her cover gown with a contaminated gloved hand to retrieve a pen. This was also confirmed by staff B, who spoke with the healthcare worker. A review of facility policy titled " Contact Precautions" dated 10/14/10 reveals that " remove gloves and gowns before leaving the patient's room or bedside in SCU and wash hands immediately before leaving the room. After glove and gown removal and hand disinfection, do not touch potentially contaminated environmental surfaces or items in the patient's room".

On 12/5/11 during facility tour on the High Observation Unit at approximately 1115 found the patient in cubicle #4 (Patient #18) had a colostomy bag that was laying on the floor. Staff B confirmed that the half-full colostomy bag was laying on the floor, and should either be hung on the rail or be placed on a blue pad.

On 12/5/11 during record review for patient #17 revealed that the patient had been in contact isolation since admission for clostridium difficile infection. On 12/1/11 the physician wrote orders to discontinue contact isolation. Interview with staff E and staff J regarding the available authority for Infection Control Officer in the facility to maintain isolation according to facility policy staff E responded "I would have kept her in (isolation)". When asked regarding the available Infection Control Officer's authority to conduct investigation, order cultures and to order or discontinue isolation staff J responded "absolutely". A review of facility policy titled " Contact Precautions" dated 10/14/10 reveals that "Contact Precautions" will be discontinued by Infection Control Practitioner or designee".


29955

On 12/6/2011 at approximately 1040 it was revealed that staff #P and staff #Q were caring for an isolation patient without tying the personal protective gown in the back. Both staff #P and staff #Q acknowledged they were not wearing the personal protective equipment as instructed.

On 12/7/2011 at approximately 1000 during a tour with dietary services, it was revealed the patient food refrigerator in the high observation unit was found to be dirty with a pinkish dried spill on the inside bottom of the unit. Staff #N confirmed the refrigerator was indeed in need of cleaning.

The refrigerator in the high observation unit was also found to contain medical lab supplies (one I-stat device and three Troponin lab containers). Staff #N and staff #L confirmed that the lab devices were not to be stored in the patient food refrigerator.

On 12/7/2011 at approximately 1010 during a tour of the general unit kitchen, it was revealed that two expired items of food were available for patient consumption. Staff #L and staff #N confirmed the items were available to be dispensed to patients to consume.

During the tour it was revealed the container for condiments in the general unit kitchen was dirty with dust and crumbs. Staff #L and staff #N confirmed the condiment container contained dirty debris.


13069

Based on observation, it was determined that the infection control system for identifying, reporting, investigating, and controlling failed to ensure compliance and/or to ensure an acceptable level of safety and quality. The findings include:

1. Chipped/missing/damaged laminates for the typical patient room doors, computer stations (charting stations) on fifth floor, central nurses' stations on both the second and fifth floors, nurses' station serving the high observation/special care unit, room 581 on the fifth floor, and wall cabinets serving the lab room on the first floor were noted with extensive damaged laminate leaving a porous (non smooth/non cleanable) surface exposed and can subject both staff and the visiting members to cuts and bruises.

2. Eight expired single serving milk and five expired single serving apple juice containers were found in the patient refrigerator serving the second floor kitchen room across form the main central nurses' station. Accompanying staff discarded the expired items and agreed better monitoring is required.

3. The typical steel storage/shelving unit in the central supply and storage room is equipped with a non cleanable/porous (particles board) plates for each unit where the hospital supplies are stored on them leaving the contact point(s) of these non cleanable surfaces subject to cross contamination.

4. The metal supply air diffusers in the dietary area exhibited rust and accumulations of dust and lint which may lead to restriction of air flow and also the possibility of food contamination. Also, the ceiling tiles next to the cooking area of the kitchen were exhibiting dust/grime accumulation.

5. The typical top surface of the typical coolers, warmers, and tray holding units in the kitchen area exhibited with dirt and lint accumulations which may lead to food contamination.


29314

On 12-5-2011at approximately 1045 during a tour of the unit it was revealed that room 511, which had been cleaned and was patient ready, had urine in the toilet, which smelled very strong when the door to the bathroom was opened. Also, the trash can had used sanitary napkins and was full. This finding was confirmed with staff C.

On 12-5-2011 at approximately 1050 during a tour of the unit it was revealed that room 549 had urine in the toilet and was also a patient ready room. Room 547 had a full trash can with food in it and was also a patient ready room. These findings were confirmed with staff C.

On 12-5-2011 at approximately 1055 during a tour of the unit it was revealed that the Bath/Shower room had used patient care supplies (cleansing body lotion, 2 bottles of foaming cleanser, a can of shaving cream, and a used razor) available for patient use.