HospitalInspections.org

Based on a review of the Healthsouth Hospital contract with an outside Hospital (Hospital #2) for reprocessing certain medical equipment (i.e., laryngoscope blades), Healthsouth Hospital failed to ensure that Hospital #2 completely adhered to the manufacturer's directions for use, to ensure safe high level disinfection. Findings include:

High level disinfection (HLD) is a cleaning process that should destroy all microorganisms, except for bacterial spores. According to the contract, Hospital #1 sent laryngoscope blades (an instrument that is inserted through a patient's mouth to facilitate passage of a tube into the lung), to Hospital #2 to undergo HLD.

However, according to the procedure form received from Hospital #2 for HLD (via fax on 7/24/12), the following step in the disinfection process was not performed in accordance with manufacturer's instructions:

The procedure did not require the instrument to be totally immersed in a large volume of fresh water for at least one minute, and repeated immersions in fresh water for a total of three separate rinses to ensure removal of chemical residue after the device was disinfected, in accordance with manufacturer's instructions. The procedure only called for the instrument to be rinsed under running water.

Based on record review and interview, the Hospital failed to provide 1 of 1 discharged patients (# 32) with the right to refuse treatment. Findings included:

The Hospital's "Patient Bill of Rights and Corporate Values" policy, last reviewed 12/2005, indicated that patients have "The right to refuse treatment to the extent provided by law and to be informed of the medical consequences of such action."

Patient #32 was admitted to the Hospital on 5/1/12 with diagnoses that included cerebral vascular accident, impaired functional mobility, dysphagia, hypertension, hyperlipidemia, and urine retention.

Record review revealed the patient was not given the information or opportunity to accept or refuse treatment including: admission information on Financial Agreements/Assignment of Benefits; acceptance of Patient Rights; Medicare information; Privacy Rights, Medical Treatment; Phone Consents and Photographic releases, as well as Invasive Treatments on 5/19/12. These agreements were signed by the patient's relative (who was also the patient's designated Health Care Proxy) on 5/1/12 and on 5/19/12, with verbal telephone consents. There was no indication that the resident had delegated these decisions to the relative, or that the relative had legal authority (such as an invoked Health Care Proxy responsibility) to make such decisions.

Interviews with the Director of Case Management on 7/24/12 at 3:45 P.M., and with the Director of Nurses and Chief Executive Officer at 4:15 P.M. confirmed the patient was not afforded the opportunity to accept or refuse the hospital's Admission Agreements for information and treatment.

Based on observation and review of the Hospital's policy, the Hospital failed to ensure consistent compliance with their policy on Patient Identification. Findings include:
Observations on the third floor inpatient unit on 7/23/12 at 4:30 P.M., indicated Rehabilitation Nursing Technician (RNT # 2 ) failed to follow Hospital procedures to ensure correct identification of a patient. RNT # 2 used a hand held glucometer that was programmed to accept the identification number of the patient. However, instead of entering the patient's identification number from the arm bracelet worn by the patient, RNT # 2 used the identification number posted on a document taped to the inside of the glucometer case, as a means to confirm the patient's identification. According to the policy entitled Patient Identification, confirmation of a patient's identity is made using "two patient specific identifiers on the armband." The practice used by RNT #2 was not consistent with the Hospital procedure for patient verification.

Based on observation, interview and documentation review, the hospital failed to ensure restraints were used only when the less restrictive interventions had been determined to be ineffective to protect 1 patient [#5] out of 1 restrained patient in a total of 30 active patients and for 1 patient [#32] in a closed sample of 1. Findings include:

1. Patient #5 was admitted to the hospital in 7/12 with diagnoses including cerebral vascular accident and mild aphasia.

Record review was conducted on 7/24/12 at 10:15 A.M.

Review of the Policy for Use of Restraints in Non-Psychiatric Hospital or Unit indicated that "The need for the use of restraints will be determined only after an appropriate assessment of the patient and evaluation of effectiveness of non-restraint interventions." The policy further indicates that "Restraints may only be initiated after care assessment of the patient and a determination that alternatives to the use of restraint have proven to be ineffective or pose a greater safety threat than the use of restraints." The policy also states that "the devices intended use ...determines whether the device used is a restraint."

Review of the Quick Screen of Cognition & Communication dated 7/9/12 indicated "patient unable to understand and follow directions for cognition screen."

Review of the nursing notes dated 7/11/12 indicated "unable to do diabetes or stroke teaching with this patient. No short or long term memory due to stroke."

Record review failed to indicate that the patient had been assessed for the use of a restraint. In addition, there was no evidence that the use of a restraint had been ordered for this patient.

Further review of nurses' notes indicated the following:
7/13/12 - Seatbelt in wheelchair due to patients impulsivity.
7/17/12 - Patient is impulsive at times. Wears alarmed seatbelt in wheelchair for safety.
7/22/12 - Patient in wheelchair with alarmed seatbelt in place. Reminded of need to keep seatbelt locked as safety reminder.

During interview on 7/24/12 at 10:15 A.M., the Chief Nursing Officer [CNO] stated that all of the facility wheelchairs have seatbelts. It was further stated the facility only obtains orders for restraints if the device is considered to be a restraint. Because the restraint device was considered to be self-releasing, the hospital did not do a restraint assessment or obtain an order for the use of the device.

During further interview on 7/24/12 at 1:20 P.M. with the Chief Executive Officer [CEO] and the CNO they both stated that they understood that the patient's inability to "understand and follow directions" and problems with "short or long term memory" created reason whereby the use of the device needed to be assessed and ordered if necessary.


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2. For Patient #32, the hospital failed to assess the patient before the initiation of four siderails while in bed and a pelvic restraint when out of bed.

Review of the closed medical record on 7/24/12 indicated Patient #32 was admitted to the hospital on 5/1/12 with diagnoses that included cerebral vascular accident, impaired functional mobility, dysphagia, hypertension, hyperlipidemia, and urine retention.

Review of the Physician's Restraint Order, dated 5/4/12 at 10:45 A.M., indicated the physician ordered the application of four (4) siderails and a pelvic restraint daily. Daily Progress Notes of 5/4/12 and the patient's 15 minute supervision notes of 5/4/12 indicated the restraints were applied on 5/4/12 at 11:00 A.M.

There was no evidence that the patient was assessed for the use of four siderails and a pelvic restraint prior to the use of the restraints.

Interview with the Director of Quality and Risk Management on 7/24/12 at 11:40 A.M. confirmed the patient should have been assessed before the physician's order for restraints and the initiation of restraints.

Based on record review and interview, the Hospital failed to ensure that for two of two patients (#12 and #30), nursing staff reviewed and revised the care plans when the patients had changes in their hydration status requiring intravenous (IV) hydration to address clinical dehydration and for one patient (#30) failed to develop a care plan to address the patient's Urinary Tract Infection (UTI) on admission.

Findings include:

1. Patient #12 was admitted 7/12/12 with diagnoses of oropharyngeal cancer, status post resection, status post tracheostomy, with decannulation on 7/15 and dysphagia.

The patient had a nasogastric tube (NGT) for feeding and was also eating an oral diet. Record review indicated that on 7/14/12, the patient pulled out the NGT and the decision was made to leave it out as the patient was taking oral feedings.

The 7/13/12 nutrition assessment assessed the patient as being a high nutrition risk and requiring 1650 cubic centimeters (ccs) of fluid a day to meet hydration needs. The nutritional care plan had interventions to include Ensure three times a day, weekly weights, speech therapy for dysphagia and NGT and oral feeding.

The care plan for falls had an intervention to monitor hydration. On 7/17/12, the nutritional care plan was updated to include concerns of loose stool with a plan to provide lactaid milk and tube feeding stopped.

Review of nursing documentation indicated the patient's intakes were as follows: 7/17 =600 cubic centimeters (ccs); 7/18 = 480; 7/19 = 960; and 7/20/12 = 720. These intakes are 50% less than the patient's requirement of 1650 ccs per day, placing the patient at risk for dehydration.

Review of the nursing notes did not indicate any interventions to address the patient's poor fluid intake, especially after the NGT was removed by the patient.

Review of the patient's Blood Urea Nitrogen (BUN) and creatinine (CR), measures of hydration status indicated the following: On admission on 7/13/12, the BUN was 28 (normal is 5-25) and the creatinine was 0.73 (normal is 0.5 -1.1). By 7/20/12, the BUN had risen to 52 and the creatinine was 0.98, indicating clinical dehydration. On 7/20/12, the physician ordered the patient to receive IV fluids of Normal Saline at 85 cc per hour for one liter.

During an interview on 7/23/12, at approximately 11:00 A.M., Nurse Manager #1 said staff should have been more aggressive with pushing fluids based on the patient's intake record.



2. Patient #30 was admitted on 7/18/12 with intraventricular hemorrhage, hypertension and urinary tract infection (UTI).

The nursing assessment, completed on 7/18/12, identified the UTI as present on admission for Patient #30, and that the patient was being treated with Nitrofurantoin. Per house policy, a repeat urine was sent on 7/19/12. On 7/20/12, the antibiotic was changed to Cipro twice a day due to sensitivity.

On 7/20/12, an elevated BUN of 33 and CR of 1.2 were reported to the Hospital with a GFR (Glomerular filtration rate) of 42, all indicators of pre-renal failure secondary to dehydration, most probably related to the UTI. On 7/20/12, the physician ordered the patient to receive an IV of Normal Saline at 80 cc's per hour for 2 liters. .

On 7/20/12, the dietitian wrote in her progress notes to push fluids. On 7/23/12, the BUN had risen to 35 and the creatinine was 1.26 with a GFR of 60.

Observation of the patient on 7/25/12 at 9:15 A.M., revealed a frail elderly person sitting in the bedside chair who was very hard of hearing. There was a large water pitcher half full of ice water on the bedside table.

Review of the nursing care plans indicated a preprinted problem and plan for urinary issues to include UTIs was in the chart but not completed. No areas under the list of problems were identified, no interventions were identified or initialed as started, no long or short term goals were identified. The care plan was not revised to address the area of dehydration and abnormal lab results.

Based on observation, record review and staff interview, the facility failed to prepare and administer medications for one patient (#16) in accordance with accepted standards of practice, out of a total sample 30 patients. Findings included:

For Patient #16, the Hospital failed to administer medications as recommended by the manufacturer's guidelines.

Patient #16 was admitted to the hospital on 7/20/12 with a diagnosis of left Cerebro-Vascular Accident with left sided weakness.

On 7/24/12 at 10:00 A.M., during the medication pass observation, RN #1 poured and administered Prednisone 1 milligram (mg) by mouth without food.

Review of the Drug Handbook, Nursing 2011, p. 1097 stated, "Give with food to reduce gastric irritation."

Record review of the Medication Administration Record of 7/12 revealed that Prednisone 1 mg daily was to be administered with food.

During an interview with Patient #16 on 7/24/12 at 10:05 A.M., he/she stated that breakfast today was at 7:30 A.M., and he/she had not taken any food since breakfast. When this Patient was questioned by the Surveyor, he/she has had some gastric distress.

During an interview with RN #1 on 7/24/12 at 10:07 A.M., the Surveyor asked when does this Patient have breakfast? RN #1 stated, "Breakfast comes at 7:00 A.M." When the Surveyor discussed the observation that food was not administered to the Patient with the Prednisone, RN #1 said that she did not give this medication with food. When RN #1 was asked why is the Prednisone scheduled to be administered at 9:00 A.M. when breakfast is at 7:00 A.M., she stated this was how Pharmacy orders the Prednisone for the Hospital.

8. Patient #3 was admitted to the facility in 7/2012.

Record review was conducted on 7/24/12 at 2:30 P.M.

Record review indicated that on 7/18, 7/19, 7/20, 7/21 and 7/23/12 progress notes were not authenticated as required. The following medical practitioners Medical Director, MD #1, PA-C #2 and PA-C #4 did not sign their progress notes.

In addition, the initial History and Physical dictated 7/17/12 was not authenticated by MD #1 and PA-C #2

9. Patient #4 was admitted to the facility in 7/2012.

Record review was conducted on 7/23/12 at 1:30 P.M.

Record review indicated that on 7/19, 7/20, 7/21, 7/22 and 7/23/12 progress notes were not authenticated as required. The following medical practitioners Medical Director, MD #1, PA-C #2, PA-C #3 and PA-C #4 did not authenticate their progress notes.

10. Patient #5 was admitted to the facility in 7/2012.

Record review was conducted on 7/24/12 at 9:30 A.M.

Record review indicated that on 7/10, 7/11, 7/12, 7/13, 7/14, 7/15, 7/16, 7/18, 7/20, 7/21 and 7/22/12 progress notes were not authenticated as required. The following medical practitioners Medical Director, MD #1, MD #2, PA-C #1,PA-C #2, PA-C #3, PA-C #4, PA-C #5, PA-C #6 and PA-C #7 did not authenticate their progress notes.

11. Patient #27 was admitted to the facility in 7/2012.

Record review was conducted on 7/25/12 at 8:45 A.M.

Record review indicated that on 7/13, 7/16, 7/19, 7/21, 7/22 and 7/23/12 progress notes were not authenticated as required. The following medical practitioners Medical Director, MD #1, PA-C #3 and PA-C #4 did not authenticate their progress notes.


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20. Patient # 9 was admitted to the hospital on 7/10/12.

Record review on 7/24/12 at 10:00 A.M., revealed that on 7/20/12,7/21/12, 7/22/12, and 7/23/12 progress notes were not authenticated as required. The following medical practitioners: Medical Director; MD #1; PA-C #1 PA -C #3, PA -C # 4, PA-C #5, and PA-C#6 did not sign their progress notes as required.

21. Patient # 25 was admitted to the hospital on 7/19/12.

Record review on 7/24/12, at 2:00 P.M., revealed that on 7/21/12, 7/23/12 and 7/24/12 progress notes were not authenticated as required. The following medical practitioners: Medical Director; MD # 1, PA-C # 1, PA-C # 4, and PA - C #5 did not sign their progress notes as required.

22. Patient #26 was admitted to the hospital on 7/18/12.

Record review on 7/25/12 at 9:45 A. M., revealed that on 7/19/12 progress notes were not authenticated as required. The following medical practitioners: MD #1 and PA-C #2 did not sign their progress notes as required.












09115

Based on record review and interview, the Hospital failed to ensure 21 of 30 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #12, #13, #14, #15, #17, #18 , #20, #25 #26, #27 and #30) active medical record entries to include physician progress notes and/or history and physicals, were authenticated [signed] in written form by the person responsible for providing or evaluating the service provided. The Hospital also failed for 1 of 30 (#11) medical orders to ensure the entries were legible and complete. Findings include:

1. Patient #12 was admitted to the Hospital in 7/2012.

Record review indicated that on 7/13, 7/14, 7/15, 7/16, 7/19, 7/20, 7/21 and 7/22/12 progress notes were not authenticated as required. The following medical practitioners medical doctor (MD) MD #2, (Physician Assistant-Certified)) PA-C #2, PA-C #3, PA-C #4 and PA-C #5, did not authenticate their progress notes.

2. Patient #14 was admitted to the Hospital in 7/2012.

Record review indicated that on 7/16/12, MD #1 and PA-C #2, did not sign the initial History and Physical. On 7/17/12, MD #1 failed to sign the Post admission evaluation. Record review indicated that on 7/19 and 7/23/12, progress notes were not authenticated as required by the following medical practitioners: MD #1, Medical Director and PA-C #3.

3. Patient #30 was admitted to the Hospital in 7/2012.

Record review indicated that on 7/20, 7/21, 7/22, 7/23 and 7/24/12, progress notes were not authenticated as required by the following medical practitioners: the Medical Director, MD #1, PA-C #1, PA-C #3, PA-C #4 and PA-C #5.



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16. Patient #1 was admitted to the Hospital in 7/2012.

Record review indicated that on 7/11, 7/12, 7/13, 7/15, 7/16, 7/17, 7/18, 7/20, 7/21 and 7/22/12 Progress and/or Physiatry Progress notes were not authenticated as required. The following medical practitioners: (Medical Director, Medical Doctors (MD) and Physician's Assistants [namely MD #1, MD#2, PA-C #2, PA-C #3, PA-C #4 and PA-C #5], did not authenticate their progress notes.

17. Patient #2 was admitted to the Hospital in 7/2012.

Record review indicated that on 7/17, 7/18, 7/19, 7/20, and 7/22/12 the Addendum to the Health and Physical (H&P), Progress and/or Physiatry Progress notes were not authenticated as required. The following medical practitioners (such as the Medical Director, Medical Doctors (MD) and Physician's Assistants (PA-Cs) [namely (MD #1, PA-C #3, and PA-C #4], did not authenticate their progress notes.

18. Patient #10 was admitted to the Hospital in 7/2012.

Record review indicated that on 7/11, 7/12, 7/13, 7/14, 7/16, 7/17, 7/18, 7/19, 7/20, 7/21 and 7/22/12, the Addendum to the Health and Physical (H&P), Progress and/or Physiatry Progress notes were not authenticated as required. The following medical practitioners (such as the Medical Director, Medical Doctors (MD) and Physician's Assistants (PA-Cs) [namely (MD #1, PA-C#2, PA-C #3, and PA-C #4], did not authenticate their progress notes.

19. Patient #20 was admitted to the Hospital in 7/2012.

Record review indicated that on 7/5, 7/6, 7/7, 7/8, 7/11, 7/9, 7/10, 7/11, 7/12, 7/13, 7/14, 5/15, 7/16, 7/17, 7/18, 7/19, 7/20, 7/21 and 7/22/12, the Progress Notes and/or Physiatry Progress notes were not authenticated as required. The following medical practitioners (such as the Medical Director, Medical Doctors (MD) and Physician's Assistants (PA-Cs) [namely (MD #1, MD# 2, PA-C#2, PA-C #3, and PA-C #4], did not authenticate their progress notes.




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4. Patient #6 was admitted to the facility in 7/2012.

Record review indicated that on 7/14, 7/15, 7/16, 7/17, 7/18, 7/19, 7/20, 7/21, and 7/23/12 progress notes were not authenticated as required. The following medical practitioners: Medical Director; MD #1; MD #2; PA-C #s 1, #3, #4, #5, and #6, and Nurse Practitioner (NP) #1 did not sign their progress notes.

5. Patient #7 was admitted to the facility in 7/2012.

Record review indicated that on 7/13, 7/14, 7/15, 7/16, 7/18, 7/19, 7/20, 7/21, and 7/23 progress notes were not authenticated as required. The following medical practitioners Medical Director, MD #1, MD #2, and PA-C #s 4, #5, and #6 did not authenticate their progress notes.

6. Patient #8 was admitted to the facility in 7/2012.

Record review indicated that on 7/23 and 7/24 progress notes were not authenticated as required. The following medical practitioners Medical Director, and PA-C #3 did not authenticate their progress notes.

7. Patient #18 was admitted to the facility in 7/2012.

Record review indicated that on 7/18, 7/19, 7/20, 7/21, and 7/23/12 progress notes were not authenticated as required. The following medical practitioners Medical Director, MD #1, PA-C #s 1, #4, and #5 did not authenticate their progress notes.



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12. For Patient #11, the Hospital failed to follow their policy for Dangerous Abbreviations, have legible physician orders for Levothyroid (a medication for hypothyroid disease) and a complete physician order for Vitamin D.

Review of the Dangerous Abbreviations/Do Not Use, revised 3/2006, stated, "Dangerous Abbreviations/Do Not Use: No Zero before a decimal point (.5) Potential Problem. This can be misread as 5 milligrams. Always use a zero before a decimal when the dose is less than a whole number."

Review of the Physician's orders of 7/14/12 at 9:00 A.M., indicated to change the following medication:

"Levothyroid .1 (unable to determine if it is an abbreviation for mg [milligrams] or mcg [micrograms] po [by mouth]) Wed and Sat. to

Levothyroid .1 (again unable to determine if it is mcg or mg) 1 1/2 po Mon., Tues, Thurs, Fri, Sun

Calcium 600 - 1 po 12, 5, 9 PM "

The dosage was not legible which could lead to a wrong dose.

During an interview with the Nurse Manager #2 on 7/25/12 at 1:35 P.M. and review of the Physician's order of 7/14/12 for Levothyroid, she stated, "They (referring to the prescribing practitioner) are suppose to put a zero before a decimal point to prevent errors an the zero is not there."

During an interview with RN #5 on 7/25/12 at 1:37 P.M., he stated that the legibility of this order was difficult, but he knew the medications this patient was taking at home.

When the Surveyor asked RN #5 what is the dose of Vitamin D for this physician's order, he stated, "There was no dose of Vitamin D ordered
with the Calcium, but the Pharmacy will change this order." A Physician's order for Vitamin D without a dosage is an incomplete medication order.



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13. Patient #13 was admitted to the Hospital on 7/2012.

Record review on 7/25/12 indicated that on 7/21 and 7/23/12 progress notes and a Physiatry consult were not authenticated as required. The following medical practitioners: Medical Director, MD #1, and PA-C #4 did not sign their documentation

14. Patient #15 was admitted to the Hospital on 7/20/12

Record review on 7/25/12 indicated that on 7/20, 7/21, 7/22 and 7/23/12, progress notes, medical addendum notes and a Physiatry consult were not authenticated as required. The following medical practitioners, Medical Director, MD #1, PA-C #2, PA-C #5, and PA-C #4 did not sign their documentation. The History and Physical on 7/20/12 was not signed by PA-C #2.

15. Patient #17 was admitted to the Hospital on 7/18/12

Record review indicated that on 7/20, 7/21, 7/22, and 7/23/12, progress notes, medical addendum notes and a Physiatry consult were not authenticated as required. The following medical practitioners, Medical Director, MD #1, PA-C #2, PA-C #5, PA-C #2 did not sign their documentation. The History and Physical on 7/20 was not signed by PA-C #2.

Based on staff interviews and review of the Hospital's Utilization Review (UR) Plan and Committee meeting minutes, on the morning of 7/24/12, indicated that the Hospital failed to ensure that the UR Committee membership was in accordance with facility policy. Findings included:

1. Review of the hospital's Utilization Review Plan on 7/24/12 revealed the Utilization Review Committee required that Committee membership (meetings) consist of two physicians.

Review of the Utilization Review Committee's meeting minutes, from 8/11 to 6/12, revealed the following:

on 8/22/11, no physicians were present,
on 9/19/11, only one physician was present,
on 10/17/11, only one physician was present,
on 11/21/11, only one physician was present,
on 12/19/11, only one physician was present,
on 1/23/12, no physicians were present,
on 1/23/12, no physicians were present,
on 2/27/12, no physicians were present,
on 3/19/12, no physicians were present,
on 4/16/12, no physicians were present,
on 5/21/12, no physicians were present,
and, on 6/18/12, only one physician was present.

Interviews with the Director of Case Management on 7/24/12 at 3:45 P.M. and with the Chief Executive Officer at 4:15 P.M. acknowledged that the hospital had not addressed the requirement for the Utilization Review Committee to have two physicians present at its monthly meetings, from 8/2011 to 6/2012.

2. During tour of the Outpatient Therapy Department on 7/23/12 at 9:00 A.M., the surveyor observed that the temperature of the Cold Pack machine was negative (-) 4 degrees Fahrenheit (F).

Review of Hospital policy and the Temperature Logs indicated the temperature of the Cold Pack machine should be between 0 and 10 degrees F., and should be checked daily. The policy included, "If temperature is not within acceptable range, tag out equipment and initiate a repair request. Highlight date and temp where the variance is present."

Review of the Temperature Logs revealed the following dates that the Cold Pack machine temperatures were not within the range per policy, and that the equipment was not "tagged out", nor was there a repair request initiated:

- 3/16/12, negative 0 degrees F.
- 04/6/12, negative 0 degrees F.
- 4/10/12, negative 0 degrees F.
- 4/17/12, negative 0 degrees F.
- 4/24/12, negative 0 degrees F.
- 05/1/12, no recorded temperature
- 05/3/12, negative 4 degrees F.
- 05/5/12, negative 0 degrees F.
- 5/11/12, negative 0 degrees F.
- 5/15/12, negative 0 degrees F.
- 5/22/12, negative 0 degrees F.
- 5/24/12, negative 0 degrees F.
- 5/25/12, negative 0 degrees F.
- 5/29/12, negative 0 degrees F.
- 5/31/12, no recorded temperature
- 06/1/12, negative 0 degrees F.
- 06/5/12, negative 0 degrees F.
- 06/8/12, negative 0 degrees F.
- 6/14/12, negative 0 degrees F.
- 6/19/12, negative 0 degrees F.
- 6/28/12, negative 0 degrees F.
- 7/10/12, negative 0 degrees F.
- 7/13/12, negative 0 degrees F.
- 7/17/12, negative 0 degrees F.
- 7/20/12, negative 0 degrees F.

During interview on 7/23/12 at 3:20 P.M., the Director of Plant Operations said the Cold Pack machine temperatures were not within acceptable limits on the above dates, and that the machine had not been tagged out with a repair request done per policy. The Director of Plant Operations said negative Zero means the temperature was less than zero.

3. Review of the Outpatient Therapy Department's 3/2012 Daily Equipment Cleaning Logs indicated no documentation that equipment which was utilized by patients (treatment tables, seats, handles, slide boards, bars, bolsters, etc.) was cleaned and disinfected daily on the following dates (5 of 20 days):

- 3/6, 3/13, 3/16, 3/20, and 3/30/12

Review of the Outpatient Therapy Department's 4/2012 Daily Equipment Cleaning Logs revealed no documentation that equipment which was utilized by patients was cleaned and disinfected daily on the following dates 7 of 23 days):

- 4/2, 4/3, 4/4, 4/10, 4/20, 4/24, and 4/30/12.

Review of the Outpatient Therapy Department's 5/2012 Daily Equipment Cleaning Logs revealed no documentation that equipment which was utilized by patients was cleaned and disinfected daily on the following dates (6 of 22 days):

- 5/1, 5/2, 5/8, 5/15, 5/18, and 5/31.

Review of the Outpatient Therapy Department's 6/2012 Daily Equipment Cleaning Logs revealed no documentation that equipment which was utilized by patients was cleaned and disinfected daily on the following dates (3 of 21 days):

- 6/8, 6/19, and 6/22/12.

Review of the Outpatient Therapy Department's 7/2012 Daily Equipment Cleaning Logs revealed no documentation that equipment which was utilized by patients was cleaned and disinfected daily on the following dates (3 of 14 days):

- 7/10, 7/17, and 7/20/12.

During interview on 7/24/12 at 10:00 A.M., the covering Outpatient Therapy Department's Supervisor acknowledged that there was no documentation of equipment cleaning and disinfection on the above dates, and that staff were required to clean and disinfect patient therapy equipment on a daily basis, per the facility policy.

4. During a tour of the Inpatient Therapy Department on 7/25/12 at 11:10 A.M., and review of the Equipment Cleaning Logs and Equipment Temperature Logs revealed no documentation that the Paraffin warming machine was cleaned on regular basis per Hospital policy. The Hospital policy regarding Equipment Cleaning (Infection Control) indicated that the Paraffin Bath machine, "Must be drained and cleaned on a monthly basis." The policy also indicated that the Cold Pac Machine "Must be thawed and cleaned on a monthly basis. During the tour on 7/25/12, the surveyor observed that the tag on the side of the Cold Pac Machine indicated the machine had not been cleaned per policy in 5/2012 and 6/2012.

During interview on 7/25/12 at 11:20 A.M., the Director of Therapy Operations said there was no documenation that the Paraffin Machine was cleaned monthly per policy, and that staff did not know who was supposed to be cleaning it.

5. During interview on 7/25/12 at 11:20 A.M., the Director of Therapy Operations said that the Inpatient Therapy Department was operational 7 days a week, and that patient equipment has to be cleaned daily. Review of the daily cleaning logs from 1/2012 to 7/2012, revealed no documentation that patient equipment was cleaned and disinfected after use on weekends.









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Based on observations, interviews, and review of the Hospital's policies/procedures and logs, the Hospital failed to consistently maintain patient care equipment to ensure an acceptable level of safety and quality.

1. Observation in the Hydrotherapy Room, interview with the Physical Therapy (PT) staff, and review of the Infection Control policy (Equipment Cleaning SOP 10.037) on July 24, 2012 in the morning, revealed that the hydrotherapy/whirlpool unit was cleaned with a dimethyl benzyl ammonium chloride and a sodium-n-chloro-paratoluene sulfonamide solution instead of a solution that creates greater than 100 ppm available chlorine, or an alcohol, phenol, or iodophor solution as recommended by The Centers for Disease Control and Prevention (CDC) Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008. According to PT staff and the Infection Preventionist, patients with intact and non-intact skin were treated in the whirlpool units.

Based on observations, interviews, and review of the Hospital's policies/procedures, logs, and employee health records, the Hospital failed to consistently ensure an acceptable level of infection prevention practice.


A. The Hospital failed to minimize the risk of cross-contamination during fingerstick blood sugar (FSBS) testing procedures. Findings include:

1. Observation of Rehabilitation Nursing Technician (RNT # 1) on 7/23/12 at 12:05 P.M., in the third floor inpatient unit, revealed the glucometer was brought into a patient's room and the glucometer case (containing the meter, test strips, finger lancets, alcohol swabs, gauze, and band-aids) was placed on the patient's bed. After direct contact with the patient, RNT #1 reached back into glucometer case to retrieve additional clean supplies to complete the procedure. After completing the procedure the glucometer was cleaned, however, the glucometer case that was placed directly on the patient's bed was not disinfected. These actions increased the risk of cross-contamination between patients.

2. Observations of Rehabilitation Nursing Technician (RNT # 3) on 7/23/12 at 4:40 P.M., in the third floor inpatient unit, revealed the glucometer was brought into a patient's room and the glucometer case (containing the meter, test strips, finger lancets, alcohol swabs, gauze, and band-aids) was placed on the patient's over-bed table. After direct contact with the patient, RNT # 3 reached back into glucometer case, repeatedly, to retrieve additional clean supplies to complete the procedure. This action increased the risk of cross-contamination of the supplies in the glucometer case.


B. The Hospital failed to ensure consistent compliance with hand hygiene standards.

Observations on the third floor inpatient unit on 7/24/2012 at 2:00 P.M., and on 7/25/2012 at 10:00 A.M., indicated that the Director of Case Management was wearing a black splint covering his/her hand and wrist. The Director of Case Management was observed entering and exiting patient rooms.

Interview with the Infection Preventionist/Occupational Health Nurse on 7/25/12 in the morning revealed the hospital required staff to complete hand hygiene upon entering and exiting the patient rooms. The patient rooms were individually labeled with "foam in, foam out" signs. According to the Infection Preventionist/Occupational Health Nurse he/she was unaware of staff wearing a splint. Review of the Hand Hygiene policy revealed the hospital had not established a process for identifying, screening and counseling health care workers who wore splints or casts to ensure the device did not limit or prevent proper hand hygiene practices.

Based on review of the Organ and Tissue Donation Policy and Procedure, review of the OPO agreement, the Hospital failed to have policies and procedures with an adequate time frame for informing the Organ Procurement Organization (OPO) of a patient's death, so tissue/organs remain viable. Findings included:

Review of the Hospital's policy and procedure on Organ and Tissue Donation, revised 5/09, under procedure #3, it states, "(The name of the OPO) will be notified by the Nurse Manager, Nurse Supervisor, or Charge Nurse within 1-2 hours of the patient's death by calling (the OPO's telephone number)." The Hospital's agreement with OPO clearly defines the Hospital's responsibility to notify the OPO within one hour of the patient's death.

During an interview with the Chief Nursing Officer and Director of Quality and Risk Management on 7/25/12 at 11:15 A.M., the Organ and Tissue Donation Policy and Procedure was reviewed. They verified that this policy has a time frame of 1 to 2 hours for notifying the OPO. They were not aware that the time frame was not in compliance with the OPO agreement and was inadequate and should be within one hour for ensuring the viability of tissues/organs.

Based on review of the Organ Procurement Organization (OPO) mutual agreement and interview, the Hospital failed to follow their agreement with the OPO for notifying the OPO in a timely manner, of patients who have died in the hospital for 2 of 3 patient death records (#33 and #34). Findings included:

Review of the OPO's agreement with the Hospital, states under, Duties of the Hospital: "The Hospital shall cooperate and work with the (name of the OPO) to identify potential donors and assist in the procurement of organs and tissue by (name of the OPO) or its designees, and shall, subject to applicable law, make available to (name of the OPO) all organs and tissues donated by patients who die in the Hospital. The Hospital 's responsibilities shall include the following: 4. Provide (name of the OPO) with 'timely notification' of all patients who have died or whose death is 'imminent.' For the purposes hereof, 'timely notification' means notification of (name of the OPO) as soon as possible after the patient has died. Timely notification of death of a non-ventilator dependent patient shall be within one hour after death of the patient has occurred."

Review of the discharged record of Patient #33 and Nurse's Note of 3/2/12 at 6:45 A.M. stated, "Pt (patient) found at 0645 with no pulse or BP (blood pressure) or respirations, no AP (apical pulse) for 60 seconds, pupils fixed and dilated. PA (Physician Assistant) notified."

Review of the Death Record indicated that the date of death was 3/2/12 and the time of death was incorrectly documented as 7:15 A.M. (which was the time of pronouncement). The OPO was notified on 3/2/12 at 8:00 A.M. (1 hour and 15 minutes after this Patient's death).

Review of the discharge record of Patient #34, the Nurses Note of 4/26/11 at 9:25 P.M. indicated , "Resp. (respiratory) ceased PA notified. Spoke with (a family member) of his/her passing."

Review of the Death Record of Patient #34 indicated that the date of death was 4/26/12 and the time of death was 9:25 P.M. The OPO was notified on 4/26/11 at 10:35 P.M. (1 hour and 10 minutes after this Patients death).

During an interview with the Chief Nursing Officer and Director of Quality and Risk Management on 7/25/12 at 11:15 A.M., and review of the Death Records for Residents #33 and #34, they verified that the OPO agreement for the 1 hour time frame notification of two patient deaths were not followed.