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Based on observation, document review, and interview, facility failed to ensure proper temperature and humidity within accepted standards of practice.


Findings:


Observation of thermo-hygrometer showed out of control-band humidity reading in procedure room, 64%.


Interview with CST (25 July 2016 @ 10:50 AM) confirmed the hygrometer showed out of control-band humidity reading in procedure room, 64%.


Review of temperature and humidity logs, showed numerous out of control-band excursions of temperature and/or humidity in OR, Procedure rooms, and sterile supply.


Interviews with CEO (21 July 2016 @ 1:50 PM) and CNO (22 July 2016 @ 3:10 PM) confirmed temperature and humidity logs showed numerous out of control-band excursions for temperature and/or humidity in OR, Procedure rooms, and sterile supply.

Based on document review and interview, facility failed to ensure that practitioners providing contracted services were required to be privileged.

Findings:

Review of bylaws indicated practitioners were required to be privileged but did not address privileging of contracted practitioners.

Review of contracted services with an anesthesia service and with a neurodiagnostics entity revealed that privileging was not addressed in either contract.

Interview with CEO (21 July 2016 @ 1:50 PM) confirmed that privileging of contracted practitioners was required and acknowledged that privileging was not addressed in the contracts nor in the bylaws for contracted provider services.

Based on document review and interview, facility failed to have a comprehensive Complaint and Grievance policy.

Findings:

Review of policy 'Patient Complaint / Grievance - Flow Chart" did not:a) contain wording stating that a written or oral complaint, when requested, would be treated as a grievance.
b) contain wording about a written complaint must be treated as a grievance.
c) contain wording about complaints of abuse by staff results in staff being retasked until investigation has been completed.

Interview with CEO (20 July 2016 @ 1:30 PM) affirmed that 'Patient Complaint / Grievance - Flow Chart" did not contain wording about a written complaint necessitating being treated as a grievance; that any complaint, either written or oral, when requested, would be treated as a grievance; or that complaints of abuse by staff results in staff being retasked until investigation has been completed.

Based on observation and interview facility failed to maintain the physical plant in a manner to ensure safety and wellbeing of patients.

Finding:

Observation revealed two (2) sprinkler heads in procedure room #2 were missing escutcheons.

Interview with CST (25 July 2016 @ 10:50 AM) confirmed that two (2) escutcheons were missing from sprinkler heads in procedure room #2.

Based on observation and interview, facility failed to ensure that equipment was maintained at an acceptable level of safety and quality.

Findings:

Observation of Bair Hugger in procedure room 3 (store room) found it to be late for maintenance. Maintenance was due on 4/16. (Current date is 7/16)

Observation Dinamap #EI 31 in PACU; found it to be late for maintenance. Maintenance was due on 4/16. (Current date is 7/16)

Interview with CST (25 July 2016 @ 11:45 AM) confirmed that Dinamap #EI 31 in PACU and Bair Hugger in procedure room 3 were both due for maintenance. Maintenance for each was due on 4/16. (Current date is 7/16)

Based on observation, document review, and interview facility failed to ensure proper ventilation and temperature controls in appropriate areas.

Findings:

Observation of thermo-hygrometer showed out of control-band humidity reading in procedure room #1, 64%.

Interview with CST (25 July 2016 @ 10:50 AM) confirmed the hygrometer showed out of control-band humidity reading in procedure room #1, 64%.

Review of temperatures and humidity logs, showed numerous out of control-band excursions of temperature and/or humidity in OR, Procedure rooms, and sterile supply.

Interviews with CEO (21 July 2016 @ 1:50 PM) and CNO (22 July 2016 @ 3:10 PM) confirmed temperature and humidity logs showed numerous out of control-band excursions for temperature and/or humidity in OR, Procedure rooms, and sterile supply.

Based on observation, document review, and interview, facility failed to mitigate risks contributing to healthcare-associated infections.

Findings:

Observation of thermo-hygrometer showed out of control-band humidity reading in procedure room, 64%.

Interview with CST (25 July 2016 @ 10:50 AM) confirmed the hygrometer showed out of control-band humidity reading in procedure room, 64%.

Review of temperature and humidity logs, showed numerous out of control-band excursions of temperature and/or humidity in OR, Procedure rooms, and sterile supply. Logs also showed numerous out of control-band temperature excursions for refrigerators and/or freezers in PACU, Med room, wound care, and patient kitchen.

Interview with CEO (21 July 2016 @ 1:50 PM) confirmed temperature logs showed numerous out of control-band excursions for temperature and/or humidity in OR, Procedure rooms, and sterile supply as well as for refrigerators and/or freezers in PACU, Med room, wound care, and patient kitchen.

Interview with CNO (22 July 2016 @ 3:10 PM) confirmed temperature and humidity logs showed numerous out of control-band excursions for temperature and/or humidity in OR, Procedure rooms, and sterile supply.

Based on document review, and interview, facility failed to complete and document a medical history and physical no more than 30 days before or 24 hours after admission.


Finding:


Document review found patient #6 (one of twenty patient records) H & P was completed outside of the acceptable window.

H & P was dated 03/05/2016, date of service was 02/17/2016.


Interview with DON (25 July 2016 @ 3:01 PM) agreed that in one of twenty patient records H & P was completed outside of the acceptable window.

Based on document review, and interview facility failed to maintain complete and up-to-date operating room register.


Findings


Document review of "SURGERY AND IMPLANT LOG" showed that:

a) 28 of 28 cases reviewed, log does not show inclusive or total time of the operation.

b) 28 of 28 cases reviewed, log does not show pre and post-op diagnosis.

c) 28 of 28 cases reviewed, log does not show anesthesia provider or other persons in attendance



Interview with DON (22 July 2016 @ 3:10 PM) confirmed that "SURGERY AND IMPLANT LOG" does not consistently show inclusive or total time of the operation, anesthesia provider, or the pre and post-op diagnosis.