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Based on the facility's policy and procedure, medical records review, and staff interviews, the facility failed to provide documentation that Medicare recipients were given a copy of the Important Message from Medicare within two (2) days of admission.

Findings were:

Review of the facility's policy entitled Revised Important Message From Medicare, revised 3-12 revealed that the original copy of the Important Message must be given at or near admission, but no later that 2 calendar days following the date of admission. The policy further revealed that the follow-up copy must be delivered as far in advance of discharge as possible, but no more than 2 calendar days before planned date of discharge. The Case Management nurse would document receipt of the follow up on the second page of the message, with date, time and nurse's name.

Review of the twenty-five (25) sampled medical records (#'s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 and 25) revealed that 7 (seven) of 8 (eight) medicare patients (#'s 9, 10, 11, 16, 18, 20 and 23) did not receive an initial copy of the Important Message From Medicare (IM).

An interview as conducted on 1/9/2013 at 10:30 a.m. in the Director of Quality and Risk Management's office (employee file # 2,), the Director of Quality stated the admission clerks were responsible for giving the Medicare patients the first copy of the IM, and the Discharge Planning department, which was one of the departments that he/she managed, was responsible for giving the second copy of the IM.

An interview was conducted on 1/9/2013 at 4:15 p.m..The Admissions Clerk (employee file #26, interview only) stated the IM was given to Medicare patients upon admission and the patients were instructed to sign the IM form during the admission process. He/she stated if the patient was unable to sign the form upon admission, the unsigned form would continue on to the floor and the nurses were then responsible for obtaining the signature. The Admissions Clerk was unaware of the second IM form that was required to be given to the Medicare patients.

Based on review of the facility's documentation related to the sterilization and high level disinfection of surgical instruments, manufacturer's directions for use, facility policies and procedures, and staff interviews, the facility failed to monitor compliance with policies, procedures, protocols and other infection control program requirements as related to aseptic (sterile) technique practices, sterilization of surgical instruments, and tracking of outpatients for surgical related infections.

Findings were:

Review of the facility's documents related to the sterilization of surgical instruments failed to reveal evidence that arthroscopes (thin flexible fiberoptic scope which is introduced into a joint space through a small incision for diagnostic or treatment procedures within the joint) were sterilized in the facility's autoclaves (machine that uses high heat and pressure to sterilize surgical instruments). Documentation in the facility's glutaraldehyde (chemical solution used to disinfect or sterilize items) log revealed that the arthroscopes were soaked in the facility's chosen disinfectant, Cidex OPA, for 12 minutes.

Review of the manufacturer's directions for use of Cidex OPA revealed instructions to select the type of germicide appropriate for the reusable device, and to determine whether the device should be processed as a critical or semi-critical device. The instructions defined a semi-critical device as one that contacts mucous membranes (such as an endoscope which is inserted through the mouth or rectum into the stomach or intestinal tract) but does not enter normally sterile tissues of the body. The instructions defined a critical item as one that enters sterile tissues of the body and which poses a high risk of infection if not sterile, such as cardiac catheters, scalpels and other surgical instruments. The instructions documented the solution was intended for use on semi-critical devices that could not be sterilized in an autoclave, and not intended for sterilization of critical devices. It did not give directions to do so.

Review of the the facility's policies and procedures, failed to reveal documented evidence of a policy which directed the follow-up of post-surgical patients for complications or infections. Documentation related to post-operative complications or infections was not provided. During an interview in the OR Director's office at 1:30 p.m. on 1/10/2013, the OR Director related that the OR did not have a system to determine if patients experienced post-operative complications or infections, and that he/she was unaware if any had occurred.

An interview was conducted in the facility's scope room at 10:40 a.m. on 1/09/2013 with the Operating Room (OR) Director (employee # 9). He/she agreed that the arthroscopes had to be sterilized prior to use, and explained that he/she had understood that soaking them in the Cidex OPA for 12 minutes sterilized them. After reviewing the directions for use provided by the manufacturer, the OR director confirmed that the facility's current process did not sterilize the instruments.

At 1:30 p.m. on 1/09/2013, the OR Director and a surgical technician (ST) related that they had corrected the non-sterile problem of the arthroscope equipment. They had contacted the instrument's manufacturer and discovered that portions of the scope could be autoclaved for sterilization, and the remaining portions could be covered with a sterile sleeve which did not impair the instrument's efficacy. This was demonstrated by the OR Director and the ST.


An interview was conducted on 1/10 /2013 at 3:00 PM in the Infection Control Practitioner's (employee #2) office. He/she stated that all surgical inpatients were tracked for surgical related infections but confirmed that surgical outpatients could be missed unless the patient returned to the facility, e.g. the emergency department, for possible surgical site infection treatment.

Based on review of the Operating Room Department's (OR) policies and procedures and staff interviews, it was determined that the OR failed to ensure that a current list of each practitioner's approved surgical procedures was maintained in the OR for immediate reference by scheduling and emergency on-call surgical staff.

Findings were:

Review of the OR's policy and procedure manual failed to reveal documentation of a list of surgical procedures that had been approved to be performed within the OR, and failed to reveal a current list of each practitioner's approved surgical procedures. Both of these documents had been requested by the surveyors during the survey's opening meeting with the hospital's Administrative staff.

During an interview in the OR Director's (employee # 9) office at 2:00 p.m. on 1/09/2013, the OR Manager confirmed that the OR did not maintain a list of approved surgical procedures. The OR Director also stated that information concerning each practitioner's approved surgical procedures was maintained in the credentialing office, which would be contacted by OR staff during regular office hours if needed. If needed after hours, emergency on-call staff would call hospital administration which would then retrieve the needed information from the credentialing office and provide it to the OR staff. The OR Director confirmed that the OR did not maintain a list of each surgical practitioner's approved surgical procedures within the OR for reference.

A. Based on review of documents related to the sterilization (process that kills or eliminates all potentially infective microorganisms, including fungi, bacteria, viruses and spores) and high level disinfection (elimination of most potentially infective microorganisms except some spores) of surgical instruments, manufacturer's directions for use, facility policies and procedures, and staff interview, it was determined that the facility 1) failed to ensure that all surgical instruments used within a sterile field were sterile; and 2) failed to follow the manufacturer's directions for use for its selected disinfectant/germicide; 3) failed to develop and implement policies related to the sterilization of arthroscopes (lighted telescopic tubes inserted into sterile tissues to visualize internal structures of the skeletal system); and 4) failed to ensure that surgical procedures were monitored for infection control purposes.

Findings were:

Review of the facility's documents related to the sterilization of surgical instruments failed to reveal evidence that arthroscopes were sterilized in the facility's autoclaves (machine that uses high heat and pressure to sterilize surgical instruments). Documentation in the facility's glutaraldehyde (chemical solution used to disinfect or sterilize items) log revealed that the arthroscopes were soaked in the facility's chosen disinfectant, Cidex OPA, for 12 minutes.

Review of the manufacturer's directions for use of Cidex OPA revealed instructions to select the type of germicide appropriate for the reusable device, and to determine whether the device should be processed as a critical or semi-critical device. The instructions defined a semi-critical device as one that contacts mucous membranes (such as an endoscope which is inserted through the mouth or rectum into the stomach or intestinal tract) but does not enter normally sterile tissues of the body. The instructions defined a critical item as one that enters sterile tissues of the body and which poses a high risk of infection if not sterile, such as cardiac catheters, scalpels and other surgical instruments. The instructions documented that the solution was intended for use on semi-critical devices that could not be sterilized in an autoclave and not intended for sterilization of critical devices. It did not give directions to do so.

Review of the the facility's policies and procedures, failed to reveal documented evidence of a policy which directed the follow-up of post-surgical patients for complications or infections. Documentation related to post-operative complications or infections was not provided. During an interview in the OR Director's office at 1:30 p.m. on 1/10/2013, the OR Director related that the OR did not have a system to determine if patients experienced post-operative complications or infections, and that he/she was unaware if any had occurred.

An interview was conducted in the facility's scope room at 10:40 a.m. on 1/09/2013 with the Operating Room (OR) Director (employee # 9). He/she agreed that the arthroscopes had to be sterilized prior to use, and explained that he/she had understood that soaking them in the Cidex OPA for 12 minutes sterilized them. After reviewing the directions for use provided by the manufacturer, the OR director confirmed that the facility's current process did not sterilize the instruments.

At 1:30 p.m. on 1/09/2013, the OR Director and a surgical technician (ST) related that they had corrected the non-sterile problem of the arthroscope equipment. They had contacted the instrument's manufacturer and discovered that portions of the scope could be autoclaved for sterilization, and the remaining portions could be covered with a sterile sleeve which did not impair the instrument's efficacy. This was demonstrated by the OR Director and the ST.


An interview was conducted on 1/10 /2013 at 3:00 PM in the Infection Control Practitioner's (employee #2) office. He/she stated that all surgical inpatients were tracked for surgical related infections but confirmed that surgical outpatients could be missed unless the patient returned to the facility, e.g. the emergency department, for possible surgical site infection treatment.






B. Based on review of policies and procedures and staff interview, it was determined that the facility failed to develop and implement appropriate policies to reduce the risk of fires associated with the use of alcohol-based skin preparations.

Findings were:

Review of the facility's policies and procedures, failed to reveal a policy which directed staff in the safe use of alcohol-based skin preparation solutions. During an interview in the OR Director's office at 1:30 p.m. on 1/09/2013, the OR Director confirmed that the facility had not developed a policy related to alcohol-based skin prep safety, but that in order to ensure that the solution was dry prior to draping, the circulator always allowed the solution to dry, inspected it visually, and would occasionally, but rarely, have to blot it in a sterile manner. The OR Director acknowledged that this process was not documented in the patient's medical record.

Based on review of the facility's policy and procedure manual, medical record review, and staff interview, the facility failed to assure the resident was provided with information regarding his/her rights and responsibilities in a manner the resident could understand and to assure the resident understood his/her rights and responsibilities.

Findings:

Review of the facility's swing bed documents, failed to reveal a policy related to providing swing bed patients with information regarding their rights. On 1/10/2013 at 3:00 p.m. the activities director provided policies and procedures utilized by the nursing home, which is attached to the hospital. The Swing Bed Activities Director (employee#4) stated his/her plan was to utilize the provided policies and procedures for the hospital's swing bed program.

Review of one (1) of two (2) sampled swing bed medical records (#'s 7 and 8), failed to reveal documentation that the patient had been given information related to patient rights.

An interview was conducted on 01/09/2013 at 3:25 p.m. in the Director's office. The Swing Bed / Activities Director stated he/she gives the patient a brochure with general information about the swing bed program and another brochure about advance directives, neither of which was documented in the chart. He/she confirmed that an activities calendar was not posted in the room however an activities assessment was done on admission.

An interview was conducted on 01/10/2013 at 1:30 p.m. in the swing bed patient' room. He/she (medical record #7) stated the staff had placed a calendar of nursing home activities on the wall and had provided information related to swing beds and patient rights last evening (01/09/2013).

Based on review of the facility's personnel file and staff interviews, it was determined that the facility's designated activities director did not meet the requirements for the position.

Findings:

Review of the personnel file for the Swing Bed Activities Director (employee #4), failed to reveal documented evidence that the Director had received the required training to qualify him/her for the position.

An interview was conducted on 01/09/2013 at 3:25 p.m. in his/her office. The Activities Director confirmed he/she had not attended training for the position.

An interview was conducted on 01/10/2013 at 11:25 a.m. in the Chief Nursing Officer's (CNO)Office. The CNO (employee #1) stated employee # 4 was going to be scheduled to attend the required training to be certified as an activity director through the Nursing Home Association.