HospitalInspections.org

Based on record review and interview, the hospital failed to meet the requirements for the Condition of Participation for Radiological Services as evidenced by:

1) failure of the Governing Body to appoint a Medical Director of the hospital's Radiological Services. (See findings tag A-0546).

2) failure to develop policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures (see findings in tag A-0536).

Based on observations, interviews and record reviews the Hospital failed to meet the requirements of the Condition of Participation in Infection Control as evidenced by:

A) failing to ensure that the designated Infection Control Officer was qualified through experience, ongoing education and/or training to be responsible for the development and implementation of the hospital's Infection Control Program. (see A-0748)
B) failing to ensure the infection control officer developed a system for investigating and controlling infections and communicable diseases of patients and personnel as evidenced by:

1) failing to maintain an ongoing Infection Control Program designed to prevent, control, and investigate infection control practices that included: data collection with analysis of infection control practices/breaches through tracking and trending activities of all the services of the hospital for infection control practices to identify needed corrective actions to prevent and control infections and to identify opportunities of improvement in infection control breaches with all infection control policies, procedures, protocols and other infection control program requirements that were implemented by the facility. This failed practice was evidenced by observations of multiple infection control breaches, no documentation of infection control data analysis to identify trends/patterns with implementation of corrective actions/measures and no documented evidence that the hospital's Infection Control Program was comprehensive and maintained as an ongoing program.

2) failing to ensure that the hospital staff followed acceptable infection control standards of practice regarding patients requiring contact precautions for 1 (#29) of 1 patient identified by the hospital as requiring contact precautions and for 9 (#1, #3, #6, #11, #20, #29, #R1, #R2, #R7) of 9 patients identified by the hospital as requiring presumptive isolation precautions out of a total census of 26,

3) failing to ensure that staff adhered to acceptable infection control practices for the cleaning/disinfecting of patient multi-use handheld glucometers,

4) failing to ensure staff followed acceptable sterilization practices for sterilization testing parameters regarding physical indicators for autoclave sterilization,

5) failing to ensure that the temperature, humidity and air cycles were monitored in the decontamination room and the sterilization room,

6) failing to ensure that staff followed the MFU for the enzymatic solution when decontaminating soiled surgical instruments prior to sterilization,

7) failing to ensure that staff adhered to the MFU for the HLD solution used for items that required HLD,

8) failing to discard single use equipment and storing the equipment in the patients' medical record for re-use on the patient,

9) failing to maintain a sanitary environment (see A-0749)

Based on observation and interview, the hospital failed to ensure patients received care in a safe setting as evidenced by having nonfunctioning nurse call lights on the handrails of patient's beds. This failure had the potential to delay or prevent assistance from nursing staff if the patient and/or family member pressed the call light on the bed rail rather than the hand held call light. Findings:

Review of the hospital's policy titled Call Devices for Patients, Policy # CL 13, revealed 1. The registered nurse shall: assure that there is a functional call light at the patient's bedside. Evaluate the patient's ability to use the standard call light.
An observation was conducted on 8/24/16 at 11:40 a.m. of Room "b" with two beds in the room with dysfunctional nursing call lights on the side rails. S2DON confirmed the nurse call lights were not working on the side rails of the bed.
An interview was conducted with S4PlantOp on 8/24/16 at 3:00 p.m. He reported a few months ago the nonfunctioning call lights on the inside of the side rails were covered but not the nonfunctioning nursing call lights on the outside of the side rails. He confirmed the nursing call lights on the outside of the side rails are still visible to the patients and the patients' family members.

Based on record reviews and interviews, the hospital failed to ensure the quality assessment performance improvement (QAPI) program showed measurable improvement in indicators for which there is evidence that it will improve health outcomes, and the governing body failed to specify the frequency and detail of data collection. This was evidenced by having 20 opportunities for improvement identified during the survey that had not been identified by the hospital.
Findings:

Review of the governing body by-laws revealed no documented evidence that the frequency and detail of data collection for the QAPI program had been specified.

In an interview on 08/26/16 at 4:30 p.m., S3QA confirmed the governing body by-laws and the QAPI policy did not state the frequency and details of data collection.

The following opportunities for improvement were identified during the survey conducted from 08/24/16 to 08/26/16:

The hospital failed to:

1) Ensure patients received care in a safe setting as evidenced by having nonfunctioning nurse call lights on the handrails of patient's beds. This failure had the potential to delay or prevent assistance from nursing staff if the patient and/or family member pressed the call light on the bed rail rather than the hand-held call light.

An interview was conducted with S4PlantOp on 8/24/16 at 3:00 p.m. He reported a few months ago the nonfunctioning call lights on the inside of the side rails were covered but not the nonfunctioning nursing call lights on the outside of the side rails. He confirmed the nursing call lights on the outside of the side rails are still visible to the patients and the patients' family members.
2) Analyze the causes of medication errors and implement preventive actions and mechanisms that include feedback and learning throughout the hospital as evidenced by failure to implement corrective action to address the medication error rate of wrong dose at 40% and omitted dose at 60% for July 2016.

In an interview on 08/26/16 at 4:30 p.m., S3QA indicated the pharmacist was working with the DON on an extensive program to address medication administration, and he left about 3 weeks ago. She further indicated the pharmacist had brought the problem before the pharmacy and therapeutics committee, but she (S3QA) had problems with the indicators. S3QA indicated she wanted to meet to narrow down the indicators that could be addressed more efficiently. She further indicated that at this point, nothing is in place to correct the above identified problem with medication wrong and omitted doses.

3) Ensure a performance improvement project was in progress as evidenced by failure of the hospital to provide documented evidence of an ongoing performance improvement project.

In an interview on 08/26/16 at 5:25 p.m., S5Dietary presented an undated document indicating the indicator was bedtime snacks with the reason for selection being bedtime "snacks were still in the refrigerator." There was no documented evidence that any data had been collected thus far and the process for conducting the project. She confirmed they had "just picked it up over the last few weeks."

4) The governing body failed to ensure the complexity of the hospital's organization and services was captured in its QAPI data and involved all hospital departments and services, including those services furnished under contract or arrangement. The QAPI program did not include quality indicators for the contracted lab, radiology, linen service, and pest control.

In an interview on 08/26/16 at 4:30 p.m., S3QA confirmed quality indicators had not been developed for the contracted lab services, radiological services, linen service, and pest control.

5) Ensure the medical staff examined the credentials of eligible candidates for medical staff membership and made recommendations to the governing body on the appointment in accordance with the medical staff by-laws as evidenced by having no documented evidence that S22MD's credentialing file had been reviewed by the medical staff and recommendation for appointment made to the governing body for 1 (S22MD) of 3 (S22MD, S28MD, S36MD) physician credentialing files reviewed from a total of 56 credentialed physicians.

In an interview on 08/26/16 at 2:35 p.m., S17RHIA confirmed S22MD had no references received prior to his reappointment by the Governing Body. She indicated 2 references are required at reappointment. She confirmed the NPDB query was conducted after S22MD had been reappointed. S17RHIA confirmed S22MD's credentialing file had no documented evidence that it had been reviewed by the medical staff with recommendation for reappointment to the Governing Body, because S22MD was the Medical Director.

6) Ensure the medical staff enforced its by-laws to carry out its responsibilities related to suspension of physicians with delinquent medical records as evidenced by having physicians with incomplete medical records within 30 days of discharge who were not suspended in accordance with the medical staff by-laws for 3 (S22, S27, S28) of 3 physicians with delinquent medical records at the time of review on 08/25/16.

In an interview on 08/25/16 at 10:45 a.m., S17RHIA indicated no process was in place for suspending physicians with delinquent medical records as required by the hospital's medical staff by-laws. She further indicated she sends a text message on her personal cell phone to notify physicians that they have delinquent medical records. S17RHIA confirmed she did not send a notice by certified mail and by facsimile or e-mail to the practitioner's office. She also confirmed the above-listed documentation was not completed as of the date of this interview.

7) Ensure the chief of the medical staff or his/her designee approved the privileges requested by the practitioner at the time of reappointment and approved by the governing body as evidenced by having no documented evidence that S22MD's requested privileges had been reviewed by the medical staff prior to his reappointment by the governing body for 1 (S22MD, S28MD, S36MD) of 3 physician credentialing files reviewed from a total of 56 credentialed physicians.

8) Ensure the RN supervised and evaluated the nursing care of each patient as evidenced by the RN failing to ensure:

a) initial wound assessments were conducted by the RN within 12 hours of admission as required by hospital policy for 3 (#1, #2, #5) of 5 (#1, #2, #3, #5, #6) patient records reviewed for wound assessments;

b) that a RN documented a nursing assessment on each patient every 24 hours as evidenced by no documented evidence of a RN assessment in the patient's medical record for 3 (#2, #4, #5) of 7 (#1 - #7) patients reviewed for RN documented assessments every 24 hours;

c) the RN assessed patients' weight as ordered by the physician as evidenced by failure to weigh patients daily in accordance with physician orders for 3 (#1, #4, #5) of 7 (#1 - #7) patient records reviewed for assessment of weights.

In an interview on 08/26/16 at 1:00 p.m. with S7WoundCare she indicated that she was the wound care nurse. She indicated that initial wound assessments should be performed within 12 hours of a patient admission and was usually done by the RN who performed the initial assessment on the patient and did not have to be performed by the wound care nurse.

In an interview on 08/25/16 at 3:05 p.m., S2DON confirmed each patient was supposed to be assessed by a RN every 24 hours. He indicated the process is supposed to be that if a LPN cares for the patient during the day, a RN is supposed to provide care during the night shift.

In an interview on 08/25/16 at 11:10 a.m., S13RN indicated when orders change from weekly weights to daily weights, it needs to be added to the weight sheet.

9) Ensure that the nursing staff developed and kept current a comprehensive nursing care plan for each patient that included target dates for the goals established in each patient's care plan as evidenced by failing to individualize patient's nursing care plans to include all the patient's medical diagnoses for which the patients were being treated, failing to set target dates for each patient's established goals, and failing to state goals in measurable terms for 4 (#1, #2, #3, #5) of 6 (#1 - #6) patient medical records reviewed for nursing care plans.

In an interview on 08/25/16 at 3:05 p.m., S2DON confirmed there were no target dates listed for patients' goals. He offered no explanation related to the goals not being stated in measurable terms.

10) Ensure drugs and biological's were administered in accordance with acceptable standards of practice for 2 of 2 (#3, #4) patients reviewed for administration of Digoxin.

An interview was conducted with S2DON on 8/25/16 at 2:40 p.m. He indicated prior to the administration of Digoxin, the nurse should take and document the patient's apical pulse on the Medication Administration Record.

11) Ensure:

a) Patient medical records were properly stored in secure locations where they are protected from water damage as evidenced by having medical records stored in the medical record room on rolling file shelves that have holes at the top of the shelving and 39 patient medical records stored on open shelves or the desk in the doctor's lounge that presents a risk for potential water damage if the sprinkler system in either area is activated.

b) All medical records were completed promptly after discharge but no later than 30 days after discharge for 4 (R3, R4, R5, R6) of 4 discharged patient records reviewed for completion within 30 days after discharge.

In an interview on 08/24/16 at 10:33 a.m., S17RHIA confirmed the patient medical records in the medical record room were exposed to potential water damage in the event that the sprinkler system was activated.

In an interview on 08/25/16 at 10:45 a.m., S17RHIA confirmed the medical records stored on the shelves and desk in the doctor's lounge were exposed to potential water damage in the event that the sprinkler system was activated.

In an interview on 08/25/16 at 10:45 a.m., S17RHIA confirmed the documentation in the medical records of Patients R3, R4, R5, and R6 was not completed within 30 days of the patients' discharge.

12) Ensure each patient's medical record entries were dated, timed, and authenticated by the person responsible for providing or evaluating the service provided as evidenced by failure to have physicians and staff authenticate medical records entries in accordance with hospital policy for 3 (#1, #5, #15) of 8 (#1 - #7, #15) patient records reviewed for authentication of medical record entries.

The lack of proper authentication was confirmed in interviews on 08/25/16 at 2:40 p.m. with S7WoundCare and on 08/25/16 at 3:05 p.m. and 5:10 p.m. with S2DON.

13) Ensure medical records included a properly executed informed consent for procedures and treatments. This deficient practice was evidenced by informed consents that were not completed as per hospital policy when information required was omitted in the informed consent, required information areas were left blank, and/or informed consents were not obtained for procedures/treatments performed for 5 (#1, #3, #4, #5, #11) of 7 (#1-7) patient records reviewed for properly executed informed consents.

The lack of properly executed consents was confirmed in interviews on 08/25/16 at 2:40 p.m. and 3:00 p.m. with S7WoundCare and on 08/25/16 at 2:50 p.m. and on 08/26/16 at 2:40 p.m. with S2DON.

14) Ensure errors in medication administration were documented in the medical record for 3 of 3 current sampled patients (#7, #11, #15) reviewed for known medication errors.

This was confirmed in interviews with S2DON on 08/25/16 at 2:50 p.m., 3:50 p.m., and 5:10 p.m.

15) Develop policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital.
In an interview 8/26/16 at 2:35 p.m. S3QA reviewed all radiology policies and procedures provided for surveyor review. S3QA reported that X-rays were taken in the hospital by a mobile x-ray contractor. S3QA confirmed the policies and procedures did not address the safety of hospital staff, patients, or visitors.
16) Ensure radiological services were under the direction of a radiologist on the medical staff, as evidenced by failure of the Governing Body to appoint a Medical Director of the hospital's Radiological Services.
In an interview 8/26/16 at 11:15 a.m. S1CEO confirmed the hospital did not have a radiologist appointed as Director of Radiological Services.

17) Ensure that the designated Infection Control Officer was qualified through experience, ongoing education and/or training to be responsible for the development and implementation of the hospital's Infection Control Program.
In an interview on 08/25/16 at 4:00 p.m. with S6IC/ClinicalManager she indicated that she was the designated Infection Control Officer for the hospital. She further indicated that she was new to the Infection Control position and had not been trained and/or had prior infection control experience. S6IC/ClinicalManager indicated that she had no documented evidence of infection control experience and/or training to present.

In an interview on 08/26/16 at 3:00 p.m. with S2DON and S3QA, they indicated that the hospital administration was aware that S6IC/ClinicalManager was not experienced and/or trained in Infection Control prior to her being designated as the Infection Control Officer, 4 (four) months ago, and had planned for her to attend a training program on 2 different occasions, but her training had been canceled on both those occasions.

18) Ensure the infection control officer developed a system for investigating and controlling infections and communicable diseases of patients and personnel.

In an interview on 08/26/16 at 2:00 p.m. with S6IC/ClinicalManager and S2DON, S6IC/ClinicalManager indicated that she was the designated Infection Control Officer for the hospital. She indicated that the hospital followed the professional standards of practice for CDC, CMS, AORN and APIC. She further indicated that since she was new to the Infection Control position and had not been trained and/or had prior infection control experience that S2DON was handling the Infection Control Program at present. S2DON was asked for the hospital's active surveillance monitoring data analysis component of the Infection Control Program that covered the hospital patients, employees, and the hospital services to include ongoing data collection and analysis with documentations of monitoring/tracking activities and data analysis, the infection control activities of the infection control program, evaluations and any indicated revisions. S2DON indicated that the infection control program activities consisted mostly of data collection to include percentages on the Infection Control Scorecard and NHSN input. S2DON indicated that the hospital department managers collected data and submitted it to him, but he was not analyzing the data for patterns/trends or infection control risks. S2DON further indicated that he only had data collection documentation (no analysis) on the Infection Control surveillance program and that there were no surveillance activities being conducted in the Infection Control Program for the monitoring of compliance of hospital policies, procedures, and protocols. S2DON had no other infection control information for the surveyor to review. S2DON indicated that he was just trying to follow the infection control activities from the prior Infection Control Officer and that he had no training/experience in the development of an Infection Control Program. S6IC/ClinicalManager was made aware of the infection control observations and interviews and of the observations during the survey (as documented below). S6IC/ClinicalManager indicated that she was not aware of all the documented infection control breaches and was not aware that the documented observations were all infection control breaches. S6IC/ClinicalManager indicated that she depended upon the hospital department managers and S2DON to alert her to any infection control issues and/or any infection control risk assessments and to know what constituted an infection control issue in their respective departments.

19) Notify the OPO (organ procurement organization), according to the hospital's agreement with the OPO, of a patient who died in the hospital, in order for the OPO to determine medical suitability for organ/tissue donation for the patient. This failed practice was evidenced in 1 (#8) of 3 (#8, #9, #10) patient medical (death) records reviewed for notification to the OPO of a patient death by the hospital.

In an interview on 08/25/16 at 2:20 p.m. with S17RHIA, Patient #8's death record and medical record was reviewed with S17RHIA. S17RHIA indicated that Patient #8's medical record had no documented evidence that the hospital notified the OPO of the patient's death after the patient had died.

20) Ensure the provision of rehabilitation services care and development of the plan of care was initiated in accordance with hospital policy as evidenced by failure to have measurable short term and long term goals described in functional or behavioral terms for 2 (#1, #5) of 8 (#1, #4, #5, #16, #17, #18, #19, #20) patient records reviewed with orders for rehabilitation services.

In an interview on 08/26/16 at 9:45 a.m., S33PT indicated Patient #1and Patient #5 were functioning well, and he didn't think they would remain on service for 14 to 28 days which is what their evaluation form requires for long term goals. He confirmed he did not develop long term goals, and he didn't explain in his documentation his reasoning for not developing long term goals.

In an interview on 08/26/16 at 10:30 a.m., S8OT indicated Patient #1 came from a rehabilitation hospital and is functioning at a high level. She further indicated when she wrote "STG's=LTG's" (short term goals equals long term goals), she meant she wasn't planning to keep Patient #1 as long as 14 to 28 days, which is what the evaluation form requires for long term goals. S8OT confirmed Patient #1 did not have long term goals developed at the time of her OT evaluation.

Based on record reviews and interviews, the hospital failed to ensure its quality assessment and performance improvement (QAPI) program included activities to track medical errors, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital as evidenced by failure to implement corrective action to address the medication error rate of wrong dose at 40% and omitted dose at 60% for July 2016.


Findings:

Review of the "Medication Errors: Error Type Analysis" revealed the percentage of wrong dose administered was as follows for 2016:

January 11%
February 17%
March 0%
April 29%
May 5%
June 3%
July 40%

Further review revealed the percentage of omitted doses of medication was as follows for 2016:

January 30%
February 50%
March 50%
April 57%
May 46%
June 61%
July 60%


Review of the "analysis/conclusions" for quarter 3 (July) revealed of the 5 this month, 3 were omissions and 2 were wrong dose. All 5 errors were the result of poor communication between nursing and pharmacy regarding changes to medication orders." Review of the recommendations/actions revealed "Nurse Manager and pharmacist working together to manage this problem."

In an interview on 08/25/16 at 3:50 p.m., S2DON confirmed the medication error rates were high and stated they had identified medication errors was a problem. S2DON then stated, "It's a PI (performance improvement) project." When asked if there was any documentation of the project, he stated no. S2DON confirmed they had not identified any corrective actions or goals for this problem at this time. S2DON stated they are holding the individual accountable.

In an interview on 08/26/16 at 4:30 p.m., S3QA indicated the pharmacist was working with the DON on an extensive program to address medication administration, and he left about 3 weeks ago. She further indicated the pharmacist had brought the problem before the pharmacy and therapeutics committee, but she (S3QA) had problems with the indicators. S3QA indicated she wanted to meet to narrow down the indicators that could be addressed more efficiently. She further indicated that at this point, nothing is in place to correct the above identified problem with medication wrong and omitted doses.



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Based on record reviews and interview, the hospital failed to ensure a performance improvement project was in progress as evidenced by failure of the hospital to provide documented evidence of an ongoing performance improvement project.

Findings:

Review of the "Annual Performance Evaluation for 2015 and Performance Improvement PLan for 2016", presented by S3QA, revealed the 2015 plan for identifying the root cause of diet errors resulted in improvement of accuracy diet orders to 100% (per cent) by July 2015.

No documentation of an ongoing performance improvement project was presented as of the conclusion of the survey on 08/26/16 at 6:30 p.m.

In an interview on 08/26/16 at 5:25 p.m., S5Dietary presented an undated document indicating the indicator was bedtime snacks with the reason for selection being bedtime "snacks were still in the refrigerator." There was no documented evidence that any data had been collected thus far and the process for conducting the project. She confirmed they had "just picked it up over the last few weeks."

Based on interview, the governing body failed to ensure that the quality assessment performance improvement (QAPI) program reflected the complexity of the hospital's organization and services and involved all hospital departments and services, including those services furnished under contract or arrangement. The QAPI program did not include quality indicators for the contracted lab, radiology, linen service, and pest control.

Findings:

In an interview on 08/26/16 at 4:30 p.m., S3QA confirmed quality indicators had not been developed for the contracted lab services, radiological services, linen service, and pest control.

Based on record reviews and interview, the hospital failed to ensure the medical staff examined the credentials of eligible candidates for medical staff membership and made recommendations to the governing body on the appointment in accordance with the medical staff by-laws as evidenced by having no documented evidence that S22MD's credentialing file had been reviewed by the medical staff and recommendation for appointment made to the governing body for 1 (S22MD) of 3 (S22MD, S28MD, S36MD) physician credentialing files reviewed from a total of 56 credentialed physicians.

Findings:

Review of the medical staff by-laws, presented as the current by-laws by S17RHIA, revealed that the medical staff coordinator will seek to verify the information submitted by the applicant for appointment and reappointment, and the application will be considered complete and ready for forwarding to the Credentials Committee when all necessary verifications have been obtained, including reference letters. The MEC (Medical Executive Committee) shall review all available information and formulate a preliminary recommendation. After considering all relevant information, the MEC shall prepare and forward a final written report and recommendation to the Governing Body. The Governing Body may adopt, reject, or modify the MEC's recommendation. Criteria for reappointment included references from other health care professionals, which must include a positive recommendation from at least one practitioner who has current personal knowledge of the applicant's clinical competence and attests to that competence in order for the member to be recommended for reappointment.

Review of S22MD's credentialing file revealed he was reappointed to the medical staff by the governing body on 04/20/16. Further review revealed the National Practitioner Data Bank (NPDB) query was conducted on 06/28/16, 2 months and 8 days after he had been reappointed. There was no documented evidence of references received. Further review revealed no documented evidence that the medical staff had reviewed S22MD's credentialing file and submitted a final written report of recommendation to the governing body.

In an interview on 08/26/16 at 2:35 p.m., S17RHIA confirmed S22MD had no references received prior to his reappointment by the Governing Body. She indicated 2 references are required at reappointment. She confirmed the NPDB query was conducted after S22MD had been reappointed. S17RHIA confirmed S22MD's credentialing file had no documented evidence that it had been reviewed by the medical staff with recommendation for reappointment to the Governing Body, because S22MD was the Medical Director.

Based on record reviews and interview, the hospital failed to ensure the medical staff enforced its by-laws to carry out its responsibilities related to suspension of physicians with delinquent medical records as evidenced by having physicians with incomplete medical records within 30 days of discharge who were not suspended in accordance with the medical staff by-laws for 3 of 3(S22MD, S27MD, S28MD) physicians with delinquent medical records at the time of review on 08/25/16.

Findings:

Review of the Medical Staff By-laws, presented as current by-laws by S17RHIA, revealed that practitioners are required to complete medical records timely and legibly in accordance with the requirements set forth in the Rules. Practitioners who are delinquent in completion of medical records will be given notice that they must complete the records in accordance with the timelines set forth in the Rules or be subject to automatic suspension of privileges. Such notice shall be sent by certified mail and by facsimile or e-mail to the practitioner's office. If the records are not completed in accordance with the Rules following such notice, the practitioner's admitting privileges will be automatically suspended and will remain automatically suspended until all of the delinquent records are completed.


Patient R3

Review of Patient R3's medical record revealed a discharge summary dictated on 06/20/16 and a medication profile report that was not signed by S22MD within 30 days of discharge. Patient R3 was discharged on 06/20/16. Further review revealed a procedure note dictated by S27MD on 05/25/16 was not signed within 30 days of discharge.


Patient R4

Review of Patient R4's medical record revealed progress notes dictated on 06/25/16 and 06/26/16 that were not signed within 30 days of discharge by S28MD.


Patient R5

Review of Patient R5's medical record revealed progress notes dictated on 07/08/16, 07/12/16, and 07/13/16 that were not signed by S28MD within 30 days of discharge.


Patient R6

Review of Patient R6's medical record revealed a telephone order dated 06/10/16 from S22MD that was not signed within 30 days of discharge. Patient R6 was discharged on 06/27/16.


In an interview on 08/25/16 at 10:45 a.m., S17RHIA indicated no process was in place for suspending physicians with delinquent medical records as required by the hospital's medical staff by-laws. She further indicated she sends a text message on her personal cell phone to notify physicians that they have delinquent medical records. S17RHIA confirmed she did not send a notice by certified mail and by facsimile or e-mail to the practitioner's office. She also confirmed the above-listed documentation was not completed as of the date of this interview.

Based on record reviews and interview, the hospital failed to ensure the chief of the medical staff or his/her designee approved the privileges requested by the practitioner at the time of reappointment and approved by the governing body as evidenced by having no documented evidence that S22MD's requested privileges had been reviewed by the medical staff prior to his reappointment by the governing body for 1(S22MD) of 3(S22MD, S28MD, S36MD) physician credentialing files reviewed from a total of 56 credentialed physicians.

Findings:

Review of the medical staff by-laws, presented as the current by-laws by S17RHIA, revealed that every practitioner who practices in the hospital must request and be granted specific delineated privileges by the governing body.

Review of S22MD's "Delineation Of Privilege Request Form" for Critical Care revealed S22MD signed the form on 02/26/16. Further review revealed the signature line for "Chief of Staff/MEC (Medical Executive Committee) Designee" was blank with the date 04/20/16 written. There was no documented evidence that a member of the medical staff reviewed S22MD's requested privileges prior to the recommendation being made for reappointment to the governing body.

In an interview on 08/26/16 at 2:35 p.m., S17RHIA confirmed S22MD's requested privileges were not reviewed by a member of the medical staff prior to the medical staff's recommendation for reappointment being made to the governing body. She indicated S22MD was the Medical Director, and she didn't realize the Vice-President of the Medical Staff could review the Medical Director's request for privileges.

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:

1) The RN failed to ensure initial wound assessments were conducted by the RN within 12 hours of admission as required by hospital policy for 3 (#1, #2, #5) of 5 (#1, #2, #3, #5, #6)patient records reviewed for wound assessments from a total of 23 patients identified by the hospital on wound care out of a total census of 30 patients.

2) The hospital failed to ensure that a RN documented a nursing assessment on each patient every 24 hours as evidenced by no documented evidence of a RN assessment in the patient's medical record for 3 (#2, #4, #5) of 7 (#1 - #7) patients reviewed for RN documented assessments every 24 hours out of a total sample of 30 patients.

3) The RN failed to assess patients' weight as ordered by the physician as evidenced by failure to weigh patients daily in accordance with physician orders for 3 (#1, #4, #5) of 7 (#1 - #7) patient records reviewed for assessment of weights from a total sample of 30 patient records.

Findings:

1) The RN failed to ensure initial wound assessments were conducted by the RN within 12 hours of admission as required by hospital policy:

A review of the hospital policy titled "Nursing Documentation" with a review date of 01/21/15 and provided by S2DON as the most current policy, revealed in part: The initial Admission Nursing Assessment will be completed by a RN within 12 (twelve) hours of inpatient admission. Wound assessment will be documented in the initial Nursing Admission Assessment document.

Patient #1

Review of Patient #1's "Initial Nursing Assessment" documented by S29RN on 08/18/16 at 4:20 p.m. revealed the wound description included "lumbar dsg (dressing) C/D/I" (clean/dry/intact). Further review of the section labeled "Wound Description" included the following titled columns for documentation: type, location, color, odor, drainage, description of dressing and surrounding tissue.

Review of Patient #1's medical record she had a wound described as "lumbar spine dehisced surgical wound" by S26LPN on 08/19/16 at 8:39 a.m. There was no documented evidence that Patient #1's wound was assessed during her initial nursing assessment.

In an interview on 08/25/16 at 2:40 p.m., S7WoundCare confirmed Patient #1's wound was not assessed at the time of the initial nursing assessment or within 12 hours of her admission.


Patient #2

The patient was a 70 year old male admitted to the hospital on 08/18/16 with an admit diagnosis of aspirate pneumonia with sepsis, acute respiratory failure, and urinary tract infection. Other diagnoses included in part: diabetes, hypertension, end stage Parkinson disease, end stage dementia, anemia, and bowel incontinent. The Initial Nursing Assessment was initiated on 08/18/16 at 8:31 p.m. by S11RN. The "Wound Description" section of the Initial Nursing Assessment was left blank. A review of the "Multi Wound Chart Detail" sheet revealed the patient's wounds were documented as assessed on 08/19/16 at 2:47 p.m. by S7WoundCare (18 hours after admission).

In an interview on 08/26/16 at 1:00 p.m. with S7WoundCare she indicated that she was the wound care nurse. She indicated that initial wound assessments should be performed within 12 hours of a patient admission and was usually done by the RN who performed the initial assessment on the patient and did not have to be performed by the wound care nurse.

In an interview on 08/25/16 at 4:00 p.m., S6IC/ClinicalManager she indicated that RNs were to perform wound assessments within 12 hours of an inpatient admission according to policy and that Patient #2's wounds should have been assessed and documented by 08/19/16 at 8:31 a.m.


Patient #5

Review of patient #5's "Initial Nursing Assessment" conducted by S30RN on 08/18/16 at 11:55 p.m. revealed a diabetic ulcer to the right heel and a blister to the left foot with no documented evidence of a description of the wounds and surrounding tissue.

Review of the "Multi Wound Chart Details" documented by S15LPN on 08/19/16 at 1:37 p.m. revealed a non-healing surgical wound to the right anterior superior upper arm, an abrasion to the right posterior upper arm, a dermatologic rash to the left breast under the breast fold, an abrasion to the left forearm, a diabetic ulcer to the right metatarsal head first, a diabetic ulcer to the right heel, and a diabetic ulcer to the left lateral foot. There was no documented evidence that a wound assessment was completed during the initial nursing assessment, and there was no documented evidence that the initial wound assessment was conducted by a RN.

In an interview on 08/25/16 at 2:40 p.m., S7Wound care confirmed Patient #5's medical record had no documented evidence that her initial wound assessments were done by a RN, because she didn't electronically sign or enter the assessment findings. She confirmed that the initial nursing assessment for Patient #5 did not include an assessment of her wounds, and there was wound assessment within 12 hours of admission as required by hospital policy.


2) The hospital failed to ensure that a RN documented a nursing assessment on each patient every 24 hours:

A review of the hospital policy titled "Nursing Documentation" with a review date of 01/21/15 and provided by S2DON as the most current policy, revealed in part: RN assessment will be completed on each patient every 24 hours via the daily nursing assessment form and corresponding daily progress notes.


Patient #2

The patient was a 70 year old male admitted to the hospital on 08/18/16 with an admit diagnosis of aspirate pneumonia with sepsis, acute respiratory failure, and urinary tract infection. Other diagnoses included in part: diabetes, hypertension, end stage Parkinson disease, end stage dementia, anemia, and bowel incontinent. A review of the daily nursing assessment sheets revealed the patient was documented as being cared for and assessed by LPNs on 08/19/16 through 08/23/16. There was no documented evidence on the daily nursing assessments sheets and/or in the corresponding daily progress notes that the patient was documented as being assessed by a RN every 24 hours.

In an interview on 08/25/16 at 10:00 a.m. with S2DON he indicated that a RN was to assess each patient every 24 hours, according to hospital policy, and document the assessments in the daily nursing assessment sheets and in the corresponding daily progress notes.


Patient #4

Review of the medical record for Patient #4 revealed she was admitted to the hospital 8/19/16 for COPD exacerbation and Acute Encephalopathy. Other diagnoses included ESRD with Hemodialysis, CAD, HTN, CHF, acute Bronchitis, and intermittent chest pain.
Further review of the nursing flowsheet and nursing notes revealed the patient was cared for and assessed by LPNs 8/20/16 through 8/24/16. No documentation of an assessment by an RN was noted 8/20/16 through 8/24/16.

In an interview 8/26/16 at 2:40 p.m. S2DON reviewed Patient #4's nursing flowsheets and notes. S2DON confirmed there was no documentation of an assessment of Patient #4 by an RN every 24 hours, as per the hospital's policy.


Patient #5

Review of Patient #5's medical record revealed she was admitted on 08/18/16 at 11:55 p.m. Review of her "Nursing Daily Flowsheet" revealed no documented evidence of an assessment by a RN every 24 hours. There was no documented evidence of a RN assessment from the night shift of 08/19/16 to the night shift of 08/21/16 and from the night shift of 08/22/16 through the night shift of 08/24/16.

In an interview on 08/25/16 at 3:05 p.m., S2DON confirmed there was no documented evidence that Patient #5 was assessed by a RN every 24 hours. He indicated the process is supposed to be that if a LPN cares for the patient during the day, a RN is supposed to provide care during the night shift.


3) The RN failed to assess patients' weight as ordered by the physician:

Patient #1

Review of Patient #1's medical record revealed her admit orders included an order to weigh on admit and weekly thereafter. Further review revealed on order on 08/23/16 at 12:06 p.m. for daily weights with a notation of "added to weights sheet."

In an interview on 08/25/16 at 11:10 a.m., S13RN indicated Patient #1 was listed on the weight sheet used to document patient weights as requiring a weekly weight. She further indicated daily weights was never added to the weight sheet when the order was received on 08/23/16. She confirmed that Patient #1 was not weighed daily on 08/23/16, 08/24/16, and 08/25/16 as ordered.


Patient #4

Review of Patient #4's physician's admit orders ,dated 8/19/16, included the order to weigh the patient on admit, weekly, and "Before and after dialysis". Further review of Patient #4's medical record revealed she received dialysis on 8/20/16, 8/21/16, 8/23/16, and another dialysis treatment that contained no date anywhere on the dialysis flowsheet. Review of the patient's dialysis flowsheets and her vital signs/ intake & outputs records revealed only 1 day (8/21/16) had her weights recorded pre- and post- dialysis.

In an interview 8/26/16 at 2:40 p.m. S2DON reviewed the medical record of Patient #4 and confirmed her weight before and after dialysis had only been recorded for 1 of 4 documented treatments. The DON reported that they should have been documented for each treatment, and that all dialysis flowsheets and other documentation should be dated.


Patient #5

Review of Patient #5's physician orders revealed an order on 08/20/16 at 11:32 a.m. for daily weights.

Review of Patient #5's "Vital Signs And Intake & (and) Output Records" revealed no documented evidence of a weight for 08/23/16 and 08/25/16.

In an interview on 08/25/16 at 2:30 p.m., S31CNA indicated there was no daily weight sheet for 08/23/16 and 08/25/16 for Patient #5. She further indicated if the weight isn't documented in the chart on the "Vital Signs And Intake & Output Records" and not in the weight book, she has no evidence to present that a weight was obtained.



30172





30420

Based on record reviews and interviews, the hospital failed to ensure that the nursing staff developed and kept current a comprehensive nursing care plan for each patient that included target dates for the goals established in each patient's care plan as evidenced by failing to individualize patient's nursing care plans to include all the patient's medical diagnoses for which the patients were being treated, failing to set target dates for each patient's established goals, and failing to state goals in measurable terms for 4 (#1, #2, #3, #5) of 6 (#1 - #6) patient medical records reviewed for nursing care plans from a sample of 30 patients. The hospital had a current census of 26 patients.

Findings:

Patient #1

Review of Patient #1's "Interdisciplinary Plan Of Care" initiated on 08/18/16 revealed problems identified were impaired mobility, decline in ADLs (activities of daily living), and altered nutrition. Further review revealed no documented evidence that a target date had been estimated for meeting these goals.

Review of the problem of impaired mobility revealed no documented evidence that the goals were stated in measurable terms as evidenced by goals stated as "return to prior level of functioning." The goal for decline in ADLs was stated as "return to prior level of function for bathing, grooming, eating, dressing." There was no description of how one would determine when these goals were met.

In an interview on 08/25/16 at 3:05 p.m., S2DON confirmed there were no target dates listed for Patient #1's goals. He offered no explanation related to the goals not being stated in measurable terms.


Patient #2

The patient was a 70 year old male admitted to the hospital on 08/18/16 with an admit diagnosis of aspirate pneumonia with sepsis, acute respiratory failure, and urinary tract infection. Other diagnoses included in part: diabetes, hypertension, end stage parkinson disease, end stage dementia, anemia, and bowel incontinent. A review of the medical record revealed care plans for impaired mobility, risk of aspiration, impaired gas exchange, altered nutrition, altered urine, risk for infection, impaired skin integrity, hyperglycemia, hypertension and altered mental status. A review of the patient's nursing notes revealed the patient was experiencing episodes of constipation. A further review of the nursing care plan revealed no documented care plans for bowel incontinence or constipation.
In an interview on 08/25/16 at 8:30 a.m. with S11RN she indicated that the patient was bowel incontinent and was experiencing episodes of constipation. She indicated that the patient should have been care planned for bowel elimination upon admit. She indicated that she was planning to develop a care plan for the patient's constipation today. S11RN further indicated that she was not sure who was responsible for setting the target dates for the goals established in each patient's care plan and indicated that the patient had no set target dates in the care plan.
A review of Patient #2's care plan again on 08/26/16 revealed no care plan had been developed for the patient's bowel elimination or constipation.

Patient #3
Review of Patient #3's diagnoses revealed she was admitted to the hospital on 8/16/16 for Failure to Thrive, Severe Malnutrition and LI to L3 transverse fractures with minimal mobility.
Review of Patient #3's care plan revealed the following identified Problem/Focus Areas: Impaired Mobility, Decline in ADLs, Fluid Volume Excess, Altered Nutrition, Altered Bowel Elimination, Altered Comfort, Altered Urine Elimination, High Risk for Injury, Impaired Skin Integrity, and High Risk for Impaired Skin. With further review of the care plan for Patient #3 revealed not target dates where set for resolution of the patient's problems.
The above findings were confirmed by S2DON on 8/25/16 at 2:50 p.m. in an interview.

Patient #5

Review of Patient #5's "Interdisciplinary Plan Of Care" initiated on 08/18/16 revealed problems identified were impaired mobility, fluid volume excess, altered nutrition, high risk for impaired skin, and hyperglycemia related to Diabetes. Further review revealed no documented evidence that a target date had been estimated for meeting these goals.

Review of the problem of impaired mobility revealed no documented evidence that the goals were stated in measurable terms as evidenced by goals stated as "return to prior level of functioning." There was no description of how one would determine when this goal was met. Further review revealed no goals were listed for the problem of high risk for impaired skin.

In an interview on 08/25/16 at 3:05 p.m., S2DON confirmed there were no target dates listed for Patient #5's goals. He offered no explanation related to the goals not being stated in measurable terms.


26351




30172

Based on record review and interview, the hospital failed to ensure drugs and biological's were administered in accordance with acceptable standards of practice for 2 of 2(#3, #4) patients reviewed for administration of Digoxin out of a sample of 30.


Findings:

Review of the reference book, Nursing 2016 Drug Handbook, revealed in part, Digoxin, Before giving drug take apical-radial pulse for 1 minute.


Patient #3

Review of Patient #3's medical record revealed her diagnoses included: Chronic diastolic heart failure and Paroxysmal Atrial fibrillation. On admission, 8/16/16, a physician's order was written for Digoxin 0.125 mg po daily.

Review of Patient #3's Medication Administration Record for 8/17/16 and 8/18/16 revealed an apical pulse was not documented prior to the Digoxin 0.125 mg being administered to the patient at 9:00 a.m. on both days (8/17/16 and 8/18/16).

An interview was conducted with S2DON on 8/25/16 at 2:30 p.m. He confirmed the above findings and reported prior to the administration of Digoxin the nurse should take and document the patient's apical pulse on the Medication Administration Record.


Patient #4

Review of Patient #4's medical record revealed her diagnoses included: End Stage Renal Disease (with Hemodialysis), COPD, CAD, HTN, CHF . A physician's order for Digoxin 0.125 po QOD was noted.

Review of Patient #4's Medication Administration Record for 8/21/16 (6:01 a.m.) to 8/22/16 at 6:00 a.m. , revealed an apical pulse was not documented prior to the Digoxin 0.125 mg being administered to the patient at 11:00 a.m. on 8/21/16. Further review of the nursing notes, nursing flowsheet, and "Vital signs and Intake & Output Record" for 8/21/16 revealed no documentation of an apical pulse at 11:00 a.m.

An interview was conducted with S2DON on 8/25/16 at 2:40 p.m. He confirmed the above findings and reported prior to the administration of Digoxin the nurse should take and document the patient's apical pulse on the Medication Administration Record.




30420

Based on observations, record reviews, and interviews, the hospital failed to:


1) Ensure patient medical records were properly stored in secure locations where they are protected from water damage as evidenced by having medical records stored in the medical record room on rolling file shelves that have holes at the top of the shelving and 39 patient medical records stored on open shelves or the desk in the doctor's lounge that presents a risk for potential water damage if the sprinkler system in either area is activated.

2) Ensure all medical records were completed promptly after discharge but no later than 30 days after discharge for 4 (R3, R4, R5, R6) of 4 discharged patient records reviewed for completion within 30 days after discharge.


Findings:

1) Ensure patient medical records were properly stored in secure locations where they are protected from water damage:

Observation in the medical record room on 08/24/16 at 10:33 a.m. revealed the patient medical records were stored on rolling shelves that when rolled together left a space between each set of shelving. Further observation revealed that each set of shelving had holes on the top surface of the shelf near the ceiling. The room was sprinklered. There was no observation of a means of protecting the patient medical records from water damage in the event the sprinkler became activated.

In an interview on 08/24/16 at 10:33 a.m. at the time of the above observation, S17RHIA confirmed the patient medical records were exposed to potential water damage in the event that the sprinkler system was activated.

Observation on 08/25/16 at 10:45 a.m. in the doctor's lounge revealed 39 patient medical records that were stored on the open file shelves or the desk awaiting physician signatures. Further observation revealed the room was sprinklered. There was no observation of a means of protecting the patient medical records from water damage in the event the sprinkler became activated.

In an interview on 08/25/16 at 10:45 a.m. at the time of the above observation, S17RHIA confirmed the medical records stored on the shelves and desk in the doctor's lounge were exposed to potential water damage in the event that the sprinkler system was activated.


2) Ensure all medical records were completed promptly after discharge but no later than 30 days after discharge:

Review of the Medical Staff By-laws, presented as current by-laws by S17RHIA, revealed that practitioners are required to complete medical records timely and legibly in accordance with the requirements set forth in the Rules.

Patient R3

Review of Patient R3's medical record revealed a discharge summary dictated on 06/20/16 and a medication profile report that was not signed by S22MD within 30 days of discharge. Patient R was discharged on 06/20/16. Further review revealed a procedure note dictated by S27MD on 05/25/16 was not signed within 30 days of discharge.

Patient R4

Review of Patient R4's medical record revealed progress notes dictated on 06/25/16 and 06/26/16 that were not signed within 30 days of discharge by S28MD.

Patient R5

Review of Patient R5's medical record revealed progress notes dictated on 07/08/16, 07/12/16, and 07/13/16 that were not signed by S28MD within 30 days of discharge.

Patient R6

Review of Patient R6's medical record revealed a telephone order dated 06/10/16 from S22MD that was not signed within 30 days of discharge. Patient R6 was discharged on 06/27/16.


In an interview on 08/25/16 at 10:45 a.m., S17RHIA confirmed the above-listed documentation was not completed within 30 days of the patients' discharge.

25065

Based on record reviews and interviews, the hospital failed to ensure each patient's medical record entries were dated, timed, and authenticated by the person responsible for providing or evaluating the service provided as evidenced by failure to have physicians and staff authenticate medical records entries in accordance with hospital policy for 3 (#1, #5, #15) of 8 (#1 - #7, #15) patient records reviewed for authentication of medical record entries from a total sample of 30 patient records.

Findings:

Review of the hospital policy titled "Authentication in Medical Record", presented as a current policy by S17RHIA, revealed that every medical record entry must be dated, timed, and authenticated. All entries shall be authenticated and consist of the professional's name or initial and professional title.


Patient #1

Review of Patient #1's "Nursing Auxilliary Notes" revealed entries made by S25LPN on 08/18/16 at 6:30 p.m., 7:40 p.m., 8:40 p.m., and 9:30 p.m. and on 08/19/16 at 1:30 a.m. and 5:30 a.m. with no documented evidence of her professional title (LPN).

Review of Patient #1's "Multi Wound Chart Details" revealed the electronic signature of S26LPN had no documented evidence of her professional title.

Review of Patient #1's "Consent For Excisional Wound Debridements" revealed no documented evidence of the date and time the nurse practitioner/physician signed the document.


Patient #5

Review of Patient #5's medical record revealed the following documentation with no documented evidence of authentication in accordance with hospital policy:
Narrative note electronically signed on 08/25/16 at 10:17 a.m. with no professional title of S15LPN;

Narrative note entry by S26LPN on 08/24/16 at 8:34 a.m. with no professional title of S26LPN;

Debridement note entered on 08/22/16 at 2:59 p.m. by S15LPN with no professional title of S15RN;

Treatment Note electronically signed by S26LPN on 08/23/16 at 3:16 p.m. with no professional title;

Narrative Note electronically signed on 08/22/16 at 3:01 p.m. by S15LPN with no professional title;

Skin Assessment electronically signed on 08/19/16 at 2:13 p.m. by S15LPN with no professional title;

Multi Wound Chart electronically signed by S15LPN on 08/19/16 at 1:37 p.m. and 2:13 p.m. with no professional title;

Lower Extremity Assessment electronically signed on 08/19/16 at 2:13 p.m. by S15LPN with no professional title;

Physician order entry signed by S15LPN on 08/22/16 at 3:01 p.m. with no professional title;
Physician order electronically signed by S15LPN on 08/19/16 at 2:10 p.m. with no professional title;

Vital Signs And Intake & (and) Output Records signature of S25LPN on 08/22/16 and 08/23/16 with no professional title;

Diabetic Record with signature of S25LPN with no professional title;

Nursing Auxilliary Notes signed by S25LPN on 08/22/16 at 8:15 p.m., 8:45 p.m., and 11:30 p.m., on 08/23/16 at 12:15 a.m., 1:40 a.m., 3:45 a.m., 5:30 a.m., 9:00 p.m., 9:20 p.m., and 11:00 p.m., on 08/24/16 at 1:45 a.m., 3:30 a.m., 5:45 a.m., 9:30 p.m. and 11:00 p.m., and on 08/25/16 at 1:00 a.m., 3:30 a.m., and 6:00 a.m. with no professional title;

Nursing Daily Flowsheet with entry by S25LPN on 08/24/16 at 6:00 p.m. and on 08/23/16 at 6:00 p.m. and 6:45 p.m. with no professional title.


In an interview on 08/25/16 at 2:40 p.m., S7WoundCare reviewed Patient #5's documentation signed by S15LPN did not include her professional title.


In an interview on 08/25/16 at 3:05 p.m., S2DON confirmed S25LPN didn't include her professional title when she authenticated her medical record entries. He confirmed the above-listed medical record authentication findings.


Patient #15

Review of the medical record for Patient #15 revealed the History & Physical documented by S20MD and dated 08/18/16 revealed no documented evidence of the time the History & Physical was conducted.

Review of the Nursing Daily Flowsheets and the Nursing Auxiliary Notes dated 08/20/16 revealed entries documented by S14RN with no indication of the professional title at 6:00 a.m., 10:00 a.m., 11:30 a.m., 12:20 p.m., 2:00 p.m., 4:00 p.m., and at 6:00 p.m.

Review of the Nursing Daily Flowsheets and the Nursing Auxiliary Notes dated 08/21/16 revealed entries documented by S14RN with no indication of the professional title at 6:00 a.m., 7:40 a.m., 9:00 a.m., 10:20 a.m., 10:55 a.m., 12:00 p.m., 3:00 p.m., 4:30 p.m., and at 6:00 p.m.

In an interview on 08/25/16 at 5:10 p.m., S2DON reviewed the medical record for Patient #15 and confirmed S14RN didn't include her professional title when she authenticated her medical record entries. He confirmed the above-listed medical record authentication findings. S2DON confirmed S20MD signed and dated the History & Physical, but failed to document the time of authentication.

Based on record reviews and interviews, the hospital failed to ensure all orders, including verbal orders, were dated, timed, and authenticated by the practitioner in accordance with state regulations for 1(#7) of 7 (# 1-7) sampled patient records reviewed for authentication of physician orders from a sample of 30 patients.


Findings:


Review the Louisiana Hospital Licensing Standards, LAC 48:I.Chapter 93, revealed the following:

Subchapter H. Medical Records Services
9387. Organization and Staffing.
E. Written orders signed by a member of the medical staff shall be required for all medications and treatments administered to patients.... The bylaws may grant the medical staff up to ten days following the date an order is transmitted verbally or electronically to provide the signature or countersignature for such order.


Patient #7
Review of the medical record for Patient #7 revealed the patient was admitted to the hospital on 08/03/16.
Further review of the record revealed the following verbal orders had not been authenticated by the practitioner within 10 days of the order:
08/03/16 at 12:35 p.m. Admission orders
08/04/16 at 10:54 a.m. Skin Care orders
08/04/16 at 9:00 p.m. PICC Line Placement Orders
08/05/16 at 7:30 a.m. Cooling Blanket ordered.
08/05/16 at 8:00 a.m. Orders for Strict Intake & Output, consult Dietary, Lantus Insulin 10 units at bedtime.
08/10/16 at 6:42 a.m. Orders to discontinue Fluconazole.
08/11/16 at 2:00 p.m. Orders for ATC trials.
08/13/16 at 2:20 p.m. Orders for Vancomycin.

In an interview on 08/25/16 at 3:50 p.m., S2DON reviewed the medical record for Patient #7 and confirmed the above verbal orders had not been authenticated by the physician within 10 days of the date the verbal order was given.







25065

Based on record reviews and interviews, the hospital failed to ensure medical records included a properly executed informed consent for procedures and treatments. This deficient practice was evidenced by informed consents that were not completed as per hospital policy when information required was omitted in the informed consent, required information areas were left blank, and/or informed consents were not obtained for procedures/treatments performed for 5 (#1, #3, #4, #5, #11) of 7 (#1-7) patient records reviewed for properly executed informed consents from a total sample of 30.


Findings:

Review of the hospital's policy titled Consents, Publication:C17, revealed in part, Before any surgical procedure or a medical procedure as defined by State Medical Disclosure panels can be performed, confirmation of the consent by the patient or an authorized person on the patient's behalf will be documented on the Disclosure and Consent for Medical and Surgical Procedures form. The duty to the obtain the consent of the patient for medical procedure rests with the physician. The form serves as a written confirmation of the patient's consent.


Patient #1

Review of Patient #1's "Consent For Excisional Wound Debridements" signed by Patient #1 on 08/22/16 at 9:35 a.m. revealed no documented evidence of the patient's condition, to include the patient's diagnosis and "description of the nature of the condition or ailment for which the medical treatment, surgical procedure or other therapy ... is indicated and recommended." This was evidenced by the blank having no writing present. Further review revealed the nurse practitioner/physician did not date and time his/her signature.

In an interview on 08/25/16 at 2:40 p.m., S7WoundCare reviewed Patient #1's record and confirmed the patient's condition was blank on the informed consent for wound debridements, and the nurse practitioner/physician didn't date and time his/her signature.


Patient #3

Review of Patient #3's medical record revealed she was admitted on 8/16/16 for L1 and L3 Traverse Fractures. Further review of her medical record revealed she had a Stage III wound on her back debrided on 8/18/16 and no informed consent was located in her medical record for the procedure.

An interview was conducted with S7WoundCare on 8/25/16 at 3:00 p.m. She was unable to locate the informed consent for the medical procedure for Patient #3.


Patient #4

Review of the medical record revealed Patient #4 was admitted to the hospital 8/19/16. Further review revealed 2 consents for Hemodialysis/Peritoneal Dialysis. The first consent was signed by Patient #4 and dated 8/20/16 at 4:20 p.m. with a staff witness signature at the same time. The consent form listed risks for Hemodialysis and those for Peritoneal Dialysis. No documentation was found as to which type of dialysis Patient #4 was to receive. The area for additional risks contained blank lines, with no writing. Further review revealed the signature line for Physician ,certifying the physician had provided and explained the information set forth in the consent , and answered all questions of the patient concerning the medical treatment and procedure, was blank, as was the date and time for a signature. Review of the second consent form for Dialysis revealed no indication or documentation of what type of dialysis Patient #4 was to receive. The areas for additional risks and physician certifications were also blank. The consent contained the signature of Patient #4, no date and time, and witnessed as indicated by a staff member signature with a date of 8/23/16, but no time as the form required.

The Consent, just above the patient's signature line read, in part, "...all applicable blanks were filled in prior to my signing..." Further review of the medical record revealed a consent for transfusion of blood and blood components. This consent for Patient #4 revealed a telephone consent was obtained via phone and signed by 3 staff members. The consent noted the patient's son first name only. The area in which the patient's condition or diagnosis requiring the recommended treatment was blank, as were the areas for additional risks particular to the patient because of a complicating medical condition and reasonable therapeutic alternatives and the risks associated with such alternatives.

In an interview 8/26/16 at 2:40 p.m. S2DON review the consents in the record of Patient #4. He verified that the consents were not completed, had blank spaces, and did not have a Physician's (or practitioner's) signature. S2DON indicated that all blanks should be filled out prior to the patient signing, the physician or practitioner obtaining the informed consent should have signed the consents, and all dates and times should be filled in. S2DON indicated that the person consenting to Patient #4 receiving blood or blood products should have been indicated by his complete name.


Patient #5

Review of Patient #5's "Consent For excisional Wound Debridements" signed by Patient #5 on 08/22/16 at 11:45 a.m. revealed no documented evidence of the patient's condition, to include the patient's diagnosis and "description of the nature of the condition or ailment for which the medical treatment, surgical procedure or other therapy ... is indicated and recommended." This was evidenced by the blank having no writing present.

In an interview on 08/25/16 at 2:40 p.m., S7WoundCare confirmed the patient's condition was blank on the informed consent for wound debridements.


Patient #11

Review of Patient #11's medical record revealed he was admitted to the hospital on 8/6/16 for Status Post Cerebrovascular Accident. With further review of the medical record revealed a PICC line was inserted into the patient on 8/8/16. No consent was found in the patient's medical record for an informed consent for the PICC line insertion.

An interview was conducted with S2DON on 8/25/16 at 2:50 p.m. He reported the contracted PICC line nurse should have obtained a consent. He was unable to locate the PICC line procedure consent for the patient.






26351





30420

Based on record review and interview, the hospital failed to ensure errors in medication administration were documented in the medical record for 3 of 3 current sampled patients (#7, #11, #15) reviewed for known medication errors out of a sample of 30 patients.


Findings:

Review of the hospital's policy titled Medication Errors, revealed when a medication error occurs the procedure included recording the medication as given in the medical record, recording notification of the physician in the medical record, and recording any actions and clinical interventions taken and the patient's response to interventions.

Review of the hospital policy titled, Medication Administration, revealed in part: 3. Documentation in the medical record shall include the following: Errors in administration of medication will be reported immediately to the attending physician, and a Notification Form will be sent to Nursing Administration and the Pharmacy Department. The actual medication administered will be documented on the medical record. Any orders received from the patient's physician and/or any necessary actions taken to protect the patient form the potential effects of the medication error will be documented in the medical record.
Review of the list of Medication Variances for the last 6 months provided by S2DON revealed current patients #7, #11, and #15 had medications variances.

Patient #7
Review of medical record for Patient #7 revealed the patient was admitted to the hospital on 08/03/16 with diagnoses of Anoxic Brain Injury and Acute Respiratory Failure. Review of the hospital's occurrence reports revealed a medication error involving Patient #7. Further review revealed Patient #7 was ordered to receive Clindamycin IV on 08/08/16 at 5:38 p.m., but the Clindamycin was not administered to Patient #7 until 08/09/16 at 11:00 a.m. The occurrence report revealed the medication was administered to Patient #11 instead.
Review of the medical record for Patient #7 revealed no documented evidence of the medication error, nor was there documentation in the record that the physician was notified of the error.

In an interview on 08/25/16 at 3:50 p.m., S2DON reviewed the medical record for Patient #7 and confirmed the above referenced medication error had not been documented in the patient's medical record. S2DON also confirmed medication errors should be documented in the patient's records.

Patient #11

Review of the medical record for Patient #11 revealed the patient was admitted to the hospital on 8/6/16 with the diagnosis of Status Post Cerebrovascular Accident.

Review of the Medication Variance Report for the last 6 months revealed Patient #11 had a medication error on 8/9/16. The medication error was listed as the patient received another patient's Clindamycin IV.

Review of the medical record for Patient #11 revealed no documented evidence of the medication error, nor was there documentation in the record that the physician was notified of the error.

In an interview on 08/25/16 at 2:50 p.m., S2DON reviewed the medical record for Patient # 11 and confirmed the above referenced medication error had not been documented in the patient's medical record and the physician had not been documented as being notified of the patient receiving another patient's antibiotic. S2DON also confirmed the medication error and the physician notification should be documented in the patient's records.

Patient #15

Review of the medical record for Patient #15 revealed the patient was admitted to the hospital on 08/17/16 with diagnoses of Diabetic Foot Ulcer, Moderate Malnutrition, and Peripheral Vascular Disease.

Review of the medication variance report dated 08/21/16 revealed the patient was ordered to receive Clinimix with electrolytes and MVI on 08/19/16. Further review of the medication variance report revealed the patient did not receive the prescribed Clinimix for 2 days.
Review of the medical record for Patient #15 revealed no documented evidence of the medication error, nor was there documentation in the record that the physician was notified of the error.


In an interview on 08/25/16 at 5:10 p.m., S2DON reviewed the medical record for Patient #15 and confirmed the medication error and the physician notification of the medication error was not documented in the patient's medical record as directed in the hospital's policy.







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Based on record review and interview, the hospital failed to develop policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital.
Findings:
Review of hospital policies and procedures, provided by S2DON as current, revealed no policy and procedure for the provision of safety of staff, and patients during radiological services.
In an interview 08/26/16 at 2:35 p.m. S3QA reviewed all radiology policies and procedures provided for surveyor review. S3QA reported that X-rays were taken in the hospital by a mobile x-ray contractor. S3QA confirmed the policies and procedures did not address the safety of hospital staff, patients, or visitors.

Based on record review and interview, the hospital failed to ensure radiological services were under the direction of a radiologist on the medical staff, as evidenced by failure of the Governing Body to appoint a Medical Director of the hospital's Radiological Services.

Findings:
Review of the hospital's organizational chart revealed no documented evidence of an appointed Medical Director of Radiological Services.
Review of the hospital's medical staff roster revealed no documented evidence of an appointed Medical Director of Radiological Services.
A review of the Governing Body meeting minutes revealed no documented evidence that the Governing Body had appointed a Medical Director of Radiological Services.
In an interview 08/26/16 at 10:15 a.m. S3QA reported the hospital did not have a physician (radiologist) appointed as Director of Radiological Services for the hospital. S3QA confirmed that diagnostic radiological tests were performed in the hospital.

In an interview 08/26/16 at 11:15 a.m. S1CEO confirmed the hospital did not have a radiologist appointed as Director of Radiological Services.

Based on record reviews and interviews, the hospital failed to ensure that the designated Infection Control Officer was qualified through experience, ongoing education and/or training to be responsible for the development and implementation of the hospital's Infection Control Program.
Findings:
A review of the hospital policy titled "Infection Prevention and Control Plan," with a hospital review date of 2014 and provided by S6IC/ClinicalManager as the most current, revealed in part: The goal is to establish a comprehensive Infection Prevention and Control Program to ensure that the hospital has a functioning coordinated process in place to minimize Healthcare Associated Infections and to optimize use of resources through a strong preventive program that incorporates surveillance, prevention and control on an ongoing basis. The management of the Infection Control Program will be be managed by an individual with knowledge that is appropriate to the level of risks identified by the hospital, as well as knowledge of the analysis of infection risks, principles of infection prevention and control, and data analysis. Qualifications of the individual responsible for the Infection Control Program may be met through ongoing education, training, experience, and/or certification in the prevention and control of infections.

A review of the Infection Control Officer's employee file, S6IC/ClinicalManager, revealed no documented evidence that the Infection Control Officer was qualified through ongoing education, training, experience, and/or certification in the prevention and control of infections. A further review of S6IC/ClinicalManager's employee file revealed no documented evidence of any infection control training/experience in the development and implementation of a hospital Infection Control Program.
In an interview on 08/25/16 at 4:00 p.m. with S6IC/ClinicalManager, she indicated that she was the designated Infection Control Officer for the hospital. She further indicated that she was new to the Infection Control position and had not been trained and/or had prior infection control experience. S6IC/ClinicalManager indicated that she had no documented evidence of infection control experience and/or training to present.

In an interview on 08/26/16 at 3:00 p.m. with S2DON and S3QA, they indicated that the hospital administration was aware that S6IC/ClinicalManager was not experienced and/or trained in Infection Control prior to her being designated as the Infection Control Officer, 4 (four) months ago, and had planned for her to attend a training program on 2 different occasions, but her training had been canceled on both those occasions.

Based on record reviews, observations and interviews, the hospital failed to ensure the infection control officer developed a system for investigating and controlling infections and communicable diseases of patients and personnel as evidenced by:
1) failing to maintain an ongoing Infection Control Program designed to prevent, control, and investigate infection control practices that included: data collection with analysis of infection control practices/breaches through tracking and trending activities of all the services of the hospital for infection control practices to identify needed corrective actions to prevent and control infections and to identify opportunities of improvement in infection control breaches with all infection control policies, procedures, protocols and other infection control program requirements that were implemented by the facility. This failed practice was evidenced by observations of multiple infection control breaches, no documentation of infection control data analysis to identify trends/patterns with implementation of corrective actions/measures and no documented evidence that the hospital's Infection Control Program was comprehensive and maintained as an ongoing program.
2) failing to ensure that the hospital staff followed acceptable infection control standards of practice regarding patients requiring contact precautions for 1 (#29) of 1 patient identified by the hospital as requiring contact precautions and for 9 (#1, #3, #6, #11, #20, #29, #R1, #R2, #R7) of 9 patients identified by the hospital as requiring presumptive isolation precautions out of a total census of 26,
3) failing to ensure that staff adhered to acceptable infection control practices for the cleaning/disinfecting of patient multi-use handheld glucometers,
4) failing to ensure staff followed acceptable sterilization practices for sterilization testing parameters regarding physical indicators for autoclave sterilization,
5) failing to ensure that the temperature, humidity and air cycles were monitored in the decontamination room and the sterilization room,
6) failing to ensure that staff followed the MFU for the enzymatic solution when decontaminating soiled surgical instruments prior to sterilization,
7) failing to ensure that staff adhered to the MFU for the HLD solution used for items that required HLD,
8) failing to discard single use equipment and storing the equipment in the patients' medical record for re-use on the patient,
9) failing to maintain a sanitary environment

Findings:
1) failing to maintain an ongoing Infection Control Program designed to prevent, control, and investigate infection control practices that included: data collection with analysis of infection control practices/breaches through tracking and trending activities of all the services of the hospital for infection control practices to identify needed corrective actions to prevent and control infections and to identify opportunities of improvement in infection control breaches with all infection control policies, procedures, protocols and other infection control program requirements that were implemented by the facility. This failed practice was evidenced by observations of multiple infection control breaches, no documentation of infection control data analysis to identify trends/patterns with implementation of corrective actions/measures and no documented evidence that the hospital's Infection Control Program was comprehensive and maintained as an ongoing program.

A review of the hospital policy titled "Infection Prevention and Control Plan," with a hospital review date of 2014 and provided by S2DON and S6IC/ClinicalManager as the most current, revealed in part: The goal is to establish a comprehensive Infection Prevention and Control Program to ensure that the hospital has a functioning coordinated process in place to minimize Healthcare Associated Infections and to optimize use of resources through a strong preventive program that incorporates surveillance, prevention and control on an ongoing basis. The policy and procedures are based in part on: APIC, CDC, CMS, AORN and state regulations. Surveillance data will be collected from all departments and will be aggregated, analyzed, and reported to the Infection Control Committee through a multidisciplinary approach. Monthly data from surveillance will be trended and reported to the Infection Control Committee. The Infection Control Committee will base the results of data trend analysis to determine the effectiveness of prevention and control strategies, along with recommended corrective actions for best practice. The management of the Infection Control Program will be be managed by an individual with knowledge that is appropriate to the level of risks identified by the hospital, as well as knowledge of the analysis of infection risks, principles of infection prevention and control, and data analysis. Qualifications of the individual responsible for the Infection Control Program may be met through ongoing education, training, experience, and/or certification in the prevention and control of infections.

A review of the hospital policy titled "Infection Surveillance," with a hospital review date of 01/22/15 and provided by S2DON and S6IC/ClinicalManager as the most current, revealed in part: Data obtained in the surveillance activities will be used to revise and improve infection reduction strategies

A review of the Infection Control Program binder and the infection control data, provided by S2DON as the complete infection control data, revealed no documented evidence of a hospital-wide active surveillance program with monitoring of compliance with all policies, procedures, and protocols and no documented evidence of hospital-wide infection control data analysis to identify trends or infection control risks.

In an interview on 08/26/16 at 2:00 p.m. with S6IC/ClinicalManager and S2DON, S6IC/ClinicalManager indicated that she was the designated Infection Control Officer for the hospital. She indicated that the hospital followed the professional standards of practice for CDC, CMS, AORN and APIC. She further indicated that since she was new to the Infection Control position and had not been trained and/or had prior infection control experience that S2DON was handling the Infection Control Program at present. S2DON was asked for the hospital's active surveillance monitoring data analysis component of the Infection Control Program that covered the hospital patients, employees, and the hospital services to include ongoing data collection and analysis with documentations of monitoring/tracking activities and data analysis, the infection control activities of the infection control program, evaluations and any indicated revisions. S2DON indicated that the infection control program activities consisted mostly of data collection to include percentages on the Infection Control Scorecard and NHSN input. S2DON indicated that the hospital department managers collected data and submitted it to him, but he was not analyzing the data for patterns/trends or infection control risks. S2DON further indicated that he only had data collection documentation (no analysis) on the Infection Control surveillance program and that there were no surveillance activities being conducted in the Infection Control Program for the monitoring of compliance of hospital policies, procedures, and protocols. S2DON had no other infection control information for the surveyor to review. S2DON indicated that he was just trying to follow the infection control activities from the prior Infection Control Officer and that he had no training/experience in the development of an Infection Control Program. S6IC/ClinicalManager was made aware of the infection control observations and interviews and of the observations during the survey (as documented below). S6IC/ClinicalManager indicated that she was not aware of all the documented infection control breaches and was not aware that the documented observations were all infection control breaches. S6IC/ClinicalManager indicated that she depended upon the hospital department managers and S2DON to alert her to any infection control issues and/or any infection control risk assessments and to know what constituted an infection control issue in their respective departments.


2) failing to ensure that the hospital staff followed acceptable infection control standards of practice regarding patients requiring contact precautions for 1 (#29) of 1 patient identified by the hospital as requiring contact precautions and for 9 (#1, #3, #6, #11, #20, #29, #R1, #R2, #R7) of 9 patients identified by the hospital as requiring presumptive isolation precautions out of a total census of 26

A review of the hospital policy titled "Transmission Based Precautions" with a revised date of 2014, provided by S6IC/ClinicalManager as the most current, revealed in part: Transmission based precautions are used when the route of transmission is not completely interrupted using standard precautions alone. Isolation precautions also apply where the presence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased potential for environmental contamination and risk of transmission. Presumptive isolation is initiated until the lab results are negative and the patient can be removed from isolation precautions.

Patient #29
A review of the patient's medical record on 08/26/16 revealed the patient was on standard precautions since her admit on 08/04/16. The patient was receiving wound care on her bilateral feet (toes) for non-healing diabetic ulcers since her admit. A review of the microbiology results from the transferring hospital, dated 08/05/16 (after her admit on 08/04/16), that were obtained from the transferring hospital's EMR around 08/17/16 by S6IC/ClinicalManager, revealed the patient was positive for MRSA. A further review of the patient's medical record revealed a physician order on 08/24/16 to obtain nasal swabs for MRSA.

An observation on 08/26/16 of Patient #29's room door revealed no isolation caddy in place indicating that the patient was not on contact precautions for MRSA.

In an interview on 08/26/16 at 11:00 a.m. with S21LPN she indicated that she had received a hands-off report earlier this week (around 08/22/16) that Patient #29 was positive for MRSA. S21LPN indicated that the staff had attempted several times to obtain nasal swabs as ordered, but the patient was refusing. S21LPN indicated that the hospital must verify with a positive MRSA report from the lab in order to place a patient on contact precautions. S21LPN indicated that the patient had been on standard precautions since her admit on 08/04/16. (Note: The microbiology results from the transferring hospital was not available on the patient's medical record and was only in a file maintained by S6IC/ClinicalManager).

In an interview on 08/26/16 at 11:15 a.m. with S6IC/ClinicalManager she indicated that the hospital was not informed by the transferring hospital that the patient had a pending culture report upon her admit, and that she had discovered the positive MRSA lab results around 08/17/16. She indicated that she thought an isolation caddy had been in place at the patient's door last week, but it was no longer in place at this time. S6IC/ClinicalManager had no further comment as to why the patient was not on contact precautions at present, but will request the staff to place an isolation caddy and a contact precaution signage on the patient's door immediately. S6IC/ClinicalManager was asked if patients with presumptive isolation were placed on isolation precautions at the time that cultures were ordered or if staff waited for the culture results before placing patients on isolation precautions. She indicated that she was not sure and that the charge nurse kept track of patients who had cultures ordered. S6IC/ClinicalManager indicated that she was new in the infection control position and was in the process of being trained in infection control.

In an interview on 08/26/16 at 2:00 p.m. with S35RN he indicated that he was the charge nurse on most days. He was asked if patients with presumptive isolation were placed on isolation precautions at the time that cultures were ordered or if staff waited for the culture results before placing patients on isolation precautions. S35RN indicated that the staff usually waited for the lab results. S35RN further indicated that 9 (#1, #3, #6, #11, #20, #29, #R1, #R2, #R7) patients had recent cultures ordered by the physicians and that 4 (#3, #11, #R1, #R2) had negative results and 3 (#6, #20, #29) patient's culture results were still pending. He indicated that 2 (#1, #R7) of the patients had positive culture reports and had been placed on the appropriate isolation precautions. S35RN further indicated that the 3 (#6, #20, #29) patients with the culture results that were still pending had not been placed on presumptive isolation precautions and that they would be placed on presumptive isolation precautions immediately.

In an interview on 08/26/16 at 2:30 p.m. with S2DON he indicated that he thought that patients were being placed on presumptive isolation, pending the lab results, and he was not aware that staff were waiting for the lab results.


3) failing to ensure that staff adhered to acceptable infection control practices for the cleaning/disinfecting of patient multi-use handheld glucometers.

A review of the MFU instruction sheet for the hospital's multi-use handheld glucometer revealed in part: The monitor needs only to be cleaned with a damp cloth and a mild detergent. Acceptable cleaning solutions include alcohol and ammonia based cleaners. There was no documented instructions for cleaning of the handheld glucometers when used as a multi-use handheld glucometer for multiple patients.

A review of the MFU instruction sheet for the EPA disinfectant used by the hospital revealed in part: Contact time: allow item to remain wet for 2 (two) minutes and then allow to dry.

An observation on 08/25/16 at 11:15 a.m. revealed the following: During an accu-check observation with S14RN on Patient #5, S14RN wiped the glucometer with the hospital EPA disinfectant and did not allow the glucometer to remain wet for 2 minutes as per MFU as indicated on the EPA disinfectant label.

In an interview on 08/25/16 at 11:25 a.m. with S14RN she indicated that she used the EPA disinfectant wipes on the glucometers instead of an alcohol pad because the EPA wipe was larger and she would have to use several alcohol wipes. She further indicated that staff had a choice and could use either an EPA disinfectant wipe or alcohol pads on the glucometer after use. S14RN indicated that she was not aware that the 2 minute contact time meant that the device had to remain wet for 2 minutes.

An observation on 08/25/16 at 3:00 p.m. revealed the following: During an accu-check observation with S18RN on Patient #7, S18RN was not observed disinfecting the glucometer after use on the patient and docked the glucometer device at the nursing station immediately after use.

In an interview on 08/25/16 at 3:25 p.m. with S18RN she indicated that she should have disinfected the glucometer with either an EPA disinfectant wipe or alcohol pads. She indicated that she mostly liked to use an EPA disinfectant wipe, instead of the alcohol pads, because the EPA wipe was bigger and further indicated that the 2 minute contact time referred to the dry time.

In an interview on 08/25/16 at 10:00 a.m., S13RN stated she was the charge nurse for the hospital. S13RN stated they had 3 glucometers on Hall "D." She stated she used alcohol pads to clean the glucometers after patient use. S13RN stated, "They say Sani-Wipes are ok, but I am old school and use alcohol because of the screen."

In an interview on 08/25/16 at 10:20 a.m., S23HBO was observed to have a glucometer machine on an overbed table in the Hyperbarics Oxygen unit. S23HBO stated he uses alcohol or Sani-Wipes to clean the glucometer after patient use.

In an interview on 08/25/16 at 4:00 p.m. with S6IC/ClinicalManager she indicated that she had instructed staff to use EPA disinfected wipes on the glucometers after each patient use. She further indicated that the hospital did not have a policy in place specific to glucometer disinfection.

4) failing to ensure staff followed acceptable sterilization practices for sterilization testing parameters regarding physical indicators for autoclave sterilization

A review of the hospital policy titled "Sterility Assurance Program," revised date of 2013 and provided by S7WoundCare as the most current, revealed in part: The sterilization integrity is confirmed by a complete cleaning, decontamination and sterility assurance program (for autoclave sterilization and HLD) for the hospital. This program provides a system of "checks and balances" according to CDC, AORN and AAMI. Preset MFU recommended cycles for correct sterilization parameters will be followed. The hospital uses HLD solutions according to the MFU. Appropriate physical monitoring devices and biologicals/chemical monitors shall be used to verify cycle parameters per MFU instructions.

A review of AORN Guidelines, 2015 edition - Guideline for Sterilization: Recommendation VI revealed in part: A quality monitoring program that includes physical monitors (printouts, digital readings, graphs and gauges), chemical indicators, and biological indicators should be used to verify that conditions necessary for steam sterilization have been met. Attention to sterility monitoring to ensure compliance with recommended guidelines is a critical component of quality assurance. Deviation from recommended practices and recommendations can compromise the quality of sterilization processes. Each sterilization cycle should be monitored to verify that parameters required for sterilization have been met. Physical monitors verify cycle parameters are met for every load. External and internal chemical indicators should be used with each package. Chemical indicators should be placed in an area within the package that presents a challenge for air removal and/or steam contact. Biological indicators should be used to monitor sterilizer efficacy and should be performed at least weekly and preferably daily.
An observation on 08/24/16 at 10:40 a.m. with S7WoundCare was made of the sterilization room that contained the hospital's gravity displaced table top autoclave. The observation revealed that the autoclave was not equipped with a physical printout device.
In an interview on 08/24/16 at 10:45 a.m. with S7WoundCare she was asked how the staff assured the physical parameters of sterilization were met since the autoclave sterilizer utilized by the hospital was not equipped with a printable printout of the physical parameters. S7WoundCare indicated that she thought the autoclave had a printable printout option, but it was not available. She further indicated that staff were not required to constantly monitor the autoclave sterilizer when it was being used to ensure the physical parameters were met during the entire sterilization cycle.


5) failing to ensure that the temperature, humidity and air cycles were monitored in the decontamination room and the sterilization room

A review of AORN Guidelines, 2015 edition- Guideline for Sterilization- Recommendation III revealed in part: A controlled environment is intended to facilitate effective decontamination, assembly, sterilization and storage and to minimize environmental contamination and maintain sterility of sterilized items. Room temperature, humidity and ventilation must be controlled and monitored in accordance with regulation. Controlled conditions reduce the risk of contamination.

A review of the "Daily Pressure, Temperature and Humidity Log" sheets for the Clean Sterile Room and the Decontamination Room from 07/25/16 to 08/26/16, as provided by S4PlantOp, revealed no documentation of the temperature, humidity or air cycles exchanges in the Clean Sterile Room and the Decontamination Room. The temperature and humidity sections were left blank.

In an interview on 08/26/16 at 9:15 a.m. with S4PlantOp he was asked for the monitoring sheets with the temperature logs for the Decontamination and the Clean Sterile rooms. He indicated that the temperature and the humidity were not monitored even though there was a space on the "Daily Pressure, Temperature and Humidity Log" sheets for this information. S4PlantOp further indicated that the hospital was not recording the air cycle exchanges in the Clean Sterile and the Decontamination rooms and he was not sure of the number of air cycle exchanges in those rooms.

6) failing to ensure that staff followed the MFU for the enzymatic solution when decontaminating soiled surgical instruments prior to sterilization

A review of AORN Guidelines, 2015 edition - Guideline for Instrument Cleaning Recommendation III revealed in part: Instruments should be cleaned and decontaminated as soon as possible after use to prevent the formation of biofilm and dried blood, to facilitate effective disinfection and sterilization. MFU should be followed for cleaning and decontamination.
A review of the MFU for the Multi-Enzyme Detergent, used to decontaminate the hospital's soiled surgical instruments, revealed in part: Dispense 1/2 to 1 (one) ounce for each 1 (one) gallon of water. Discard solution after each use. The water temperature of the solution should be between 90 -110 F for a 1-2 minute contact time.

In an interview on 08/24/16 at 11:00 a.m. with S7WoundCare she indicated that she was responsible for the decontamination and reprocessing of the surgical instruments (for wound care debridement) used in the hospital. S7WoundCare indicated that she was not monitoring or testing the water temperature of the enzymatic solution prior to use and was not aware that it was required.

An observation in the Materials Management Room on 08/24/16 at 10:40 a.m., with S10MaterialMgmt present, revealed two containers of one gallon Enzymatic Detergent and Presoak (used in decontamination of instruments) that expired on 04/17/16.

In an interview on 08/24/16 at 10:40 a.m., S10MaterialMgmt indicated they put a red dot on the shelf of items that have an expiration date. He further indicated the shelf that had the Enzymatic Detergent and Presoak did not have a red dot, and that's probably why the product wasn't checked monthly. He further indicated he was not aware of a policy that addressed the hospital's practice of basing the checking for expired products on the red dot system.


7) failing to ensure that staff adhered to the MFU for the HLD solution used for items that required HLD

A review of AORN Guidelines, 2016 edition, Recommended Practice for High-Level Disinfectant, Recommendation IV revealed in part: High-Level Disinfectant (HLD) should occur at appropriate temperatures, contact time, and length of use. Improper use of HLD can cause contamination and lead to outbreaks. HLD should be used according to MFU.

A review of the MFU as noted on the hospital's HLD solution bottle revealed in part: The HLD solution does not require pre-mixing and the HLD solution bottle once opened will expire in 75 days. The HLD solution is a HLD for reprocessing heat sensitive semi-critical devices when used according to the MFU. Manual Processing Instructions: the HLD solution should be at a minimum of 20 degrees C or 68 degrees F when used or reused as a HLD and the solution should be at or above its MEC as determined by the HLD solution test strips. The HLD solution when poured into another sterile container can be used or reused for a maximum of 14 days provided the required condition of the concentration and temperature exist based upon monitoring described in the MFU. Do not rely solely on expiration dates.
A review of the HLD log, as provided by S7WoundCare, from 05/17/16 to 08/22/16 revealed no documented evidence that the HLD, when used, was monitored for temperature requirements as per the MFU instructions.
In an interview on 08/24/16 at 10:40 a.m. with S7WoundCare, she indicated that she was responsible for the HLD protocols for the hospital. S7WoundCare was asked for the HLD log that contained the monitoring of the HLD solution's temperature. S7WoundCare indicated that she did not monitor the HLD's solution temperature and was not aware that she had to monitor the temperature of the HLD prior to use.
8) failing to discard single use equipment and storing the equipment in the patients' medical record for re-use on the patient
Review of the Hospital's policy titled "Standard Precautions" revised on 01/22/15 revealed in part: Single use items are properly discarded after single use.
An observation was conducted of Patient #22 and Patient #24's outpatient medical records on 08/26/16 at 1:00 p.m. Both medical records had "used" single-use scalpels and scissors in biohazard bags folded in the patients' medical records. The medical records were obtained at the outpatient front desk from a file cabinet.

An interview was conducted with S19OP on 08/26/16 at 1:00 p.m. She reported that both patients had wound vacs and the nurses would reuse the scalpels and scissors at the patients' next visit to cut the foam for the wound vac.

Review of the packaging label for the Suture Removal Tray (that contained the scissors) revealed it was a single use devise.

Review of the packaging label for the Scalpel revealed that the Disposable Scapel Stainless Steel Blade, after use, should be disposed of in a puncture resistant container.

9) failing to maintain a sanitary environment as evidenced by:
a) 41 hospital beds in a hospital certified for 56 beds had rust on the beds and could not be properly disinfected.

An observation was conducted on 08/24/16 at 11:30 a.m. of Room "b." Room "b" had two empty beds in the room ready for an admission of a patient. The two beds had rust on both of the bedrails. An interview was conducted with the S2DON on 08/24/16 at 11:40 a.m. He confirmed the beds' side rails did have rust on both of them.
After requesting a count of beds in use that had rust on them from S4PlantOp, an interview was conducted with S4PlantOp on 08/24/16 at 3:00 p.m. He reported 41 beds in use in the hospital had rust on them.
b) The countertop in the dialysis room having exposed disintegrating particle board that was unable to be properly disinfected.

An observation was conducted on 08/24/16 at 10:15 a.m. of the dialysis room. The counter top near the sink area in the dialysis room had exposed, disintegrating particle board on the counter top and under the sink. The particle board was unable to be disinfected properly.
An interview was conducted with S9Dialysis on 08/24/16 at 11:30 a.m. He reported the hospital was aware of the need for a new counter area due to the exposed particle board and the inability to disinfect the area.
c) 1 out of 2 dialysis machines having rust on the machine and could not be properly disinfected.
An observation was conducted in the dialysis room on 08/24/16 at 10:15 a.m. and one of the two dialysis machines in the room had rust at the bottom of the machine.
An interview was conducted with S9Dialysis on 08/24/16 at 11:30 a.m. He reported the dialysis company was looking into recoating the machine due to the rust.
d) Items being stored on the floor of the dietary dry storage room.

An observation was conducted on 08/24/16 at 10:15 a.m. in the dry dietary storage room of 4 cases of water and 1 box of aluminum pans stored on the floor.
The above findings were confirmed by S4PlantOp in an interview on 08/24/16 at 10:15 a.m. He reported they should not be stored on the floor.
e) 2 out of 2 oxygen concentrators in the dialysis room had a coating of dust on the top of the concentrators.

An observation was conducted on 08/24/16 at 10:25 a.m. of 2 out of 2 oxygen concentrators in the dialysis room that had a layer of dust over the top of the machines. The above findings were confirmed by S2DON at the time of the observation.

On 08/25/16 at 10:20 a.m. an observation was made in the Hyperbaric Oxygen Unit with S23HBO. A large accumulation of dust was observed on the return air vent in the unit. S23HBO confirmed the accumulation of dust on the return air vent. He stated the filter for the return air vent had been recently changed and stated he thought there was a lot of dust due to the air condition. Dust accumulation was also observed on the desk/work area. S23HBO stated he cleans the desk frequently but a large amount of dust accumulates in the unit.

f) Expired supplies available for use.

An observation 08/24/16 at 11:35 a.m. revealed, in the medication room on Hall D, 3 of 3 general culture swabs with an expiration date of 05/2015, and 1 of 1 "Mini 2 to 1" IV Administration extension set with an expiration date of 03/2016. S1CEO, present for the observation, confirmed the supplies and expiration dates. S1CEO verified the expired supplies should not be available for use, and should have been disposed of.

Observation in the Materials Management Room on 08/24/16 at 10:40 a.m., with S10MaterialMgmt present, revealed 4 bottles of 500 milliliters Medline Sterile 0.9% (per cent) Normal Saline that expired June 2016.

In an interview on 08/24/16 at 10:40 a.m., S10MaterialMgmt indicated they put a red dot on the shelf of items that have an expiration date. He further indicated he wasn't aware of a policy that addressed the hospital's practice of basing the checking for expired products on the red dot system. During the same interview, S2DON confirmed the bottles of Normal Saline had expired in June 2016.

g) Isolation of patients not within standards of care.

An observation on 08/24/16 at 11:25 a.m. revealed patient room "a," with a PPE holder (isolation caddy) hung on the door. Further observation revealed no signage of isolation type. S2DON, present for the observation, reported that he did not know what type of isolation the patient was in or for what reason the patient was in isolation.

h) Observation on 08/24/16 at 11:45 a.m. revealed the Biohazard/Dirty Linen Room on Hall B did not have a biohazard label on the door and an open rolling bin of clean laundry was uncovered in the linen room on Hall D. This observation was confirmed by S2DON.

i) Observation on 08/24/16 at 11:40 a.m. in the patient bathroom in Hall B revealed an unlabeled medicine cup with green liquid and an opened bottle of soap on the ledge of the bath tub.

In an interview at the time of the observation on 08/24/16 at 11:40 a.m., S2DON indicated the green liquid looked like shampoo. He further indicated neither the shampoo or the soap should have been left in the patient bathroom, because they are not products to be shared between patients.

An observation on 08/24/16 at 10:50 a.m. revealed, in a (common) patient shower located on Hall B, revealed a medication cup approximately 1/2 full of green liquid, identified as shampoo by S2DON, present during the observation. Further observation revealed an opened container of body soap with labeling that included, "do not share," and a bottle of "Soothe and Cool body spray, also with no patient label. S2DON reported hygiene products were not labeled for any particular patient and should not be in the bathroom and available for use. The soap dispenser at the handwashing sink was observed to be empty.


In an interview on 08/25/16 at 4:00 p.m. with S6IC/ClinicalManager, she indicated that she was the designated Infection Control Officer. S6IC/ClinicalManager was made aware of the above infection control breaches. During the interview, as she was made aware of the infection control breaches, S6IC/ClinicalManager indicated to the surveyor that she had no infection control experience and/or training and was not familiar with all of the significance of the above infection control breaches and had only been the Infection Control Officer for 4 months.


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Based on record reviews and interview the hospital failed to notify the OPO, according to the hospital's agreement with the OPO, of a patient who died in the hospital in order for the OPO to determine medical suitability for organ/tissue donation for the patient. This failed practice was evidenced in 1 (#8) of 3 (#8, #9, #10) patient medical (death) records reviewed for notification to the OPO of a patient death by the hospital out of a total sample of 30.

Findings:

A review of the hospital policy titled "Organ and Tissue Donation", provided by S2DON as the most current, revealed in part: The hospital will report all deaths to the hospital's OPO for the OPO to evaluate for potential organ and tissue donation.

A review of the the death record for Patient #8 revealed the patient died on 06/17/16 at 11:20 a.m. A further review of the death record revealed no documented evidence that the hospital's OPO was notified of the patient's death on 06/17/16.

In an interview on 08/25/16 at 2:20 p.m. with S17RHIA, Patient #8's death record and medical record was reviewed with S17RHIA. S17RHIA indicated that Patient #8's medical record had no documented evidence that the hospital notified the OPO of the patient's death after the patient had died.

Based on record reviews and interviews, the hospital failed to ensure the provision of rehabilitation services care and development of the plan of care was initiated in accordance with hospital policy as evidenced by failure to have measurable short term and long term goals described in functional or behavioral terms for 2 (#1, #5) of 8 (#1, #4, #5, #16, #17, #18, #19, #20) patient records reviewed with orders for rehabilitation services from a total sample of 30 patient records.

Findings:

Review of the hospital policy titled "Initial Evaluation Of Patients/Receiving Orders", presented as a current policy by S3QA, revealed that a comprehensive rehabilitation services treatment plan will be developed and implemented by a qualified therapist for all patients who are deemed to be candidates for beneficial outcome from rehabilitation services provided. Based on information gathered, measurable short term and long term goals, which are described in functional or behavioral terms, are established.


Patient #1

Review of Patient #1's "Occupational Therapy Initial Evaluation" conducted on 08/19/16 at 5:03 p.m. by S8OT revealed long term goals were documented as "STG's=LTG's" (short term goals equals long term goals).

Review of Patient #1's "Physical Therapy Initial Evaluation" conducted by S33PT on 08/19/16 at 4:30 p.m. revealed no documented evidence of long terms developed as evidenced by the section for long term goals being blank.

In an interview on 08/26/16 at 9:45 a.m., S33PT indicated Patient #1 was functioning well, and he didn't think she would remain on service for 14 to 28 days which is what their evaluation form requires for long term goals. He confirmed he did not develop long term goals, and he didn't explain in his documentation his reasoning for not developing long term goals.

In an interview on 08/26/16 at 10:30 a.m., S8OT indicated Patient #1 came from a rehabilitation hospital and is functioning at a high level. She further indicated when she wrote "STG's=LTG's", she meant she wasn't planning to keep Patient #1 as long as 14 to 28 days, which is what the evaluation form requires for long term goals. S8OT confirmed Patient #1 did not have long term goals developed at the time of her OT evaluation.


Patient #5

Review of Patient #5's "Physical Therapy Initial Evaluation" conducted by S33PT on 08/19/16 at 4:05 p.m. revealed no documented evidence of long terms developed as evidenced by the section for long term goals being blank.

In an interview on 08/26/16 at 9:45 a.m., S33PT indicated Patient #5 was functioning well, and he didn't think she would remain on service for 14 to 28 days which is what their evaluation form requires for long term goals. He confirmed he did not develop long term goals, and he didn't explain in his documentation his reasoning for not developing long term goals.