HospitalInspections.org

The Governing Body failed to;

A.)

1.)
take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are sustained for 20 out of 20 months (January 2016-August of 2017).

Refer to Tag A0283

2.)
provide an ongoing program that showed measurable improvement in indicators for which there is evidence that the program/process would identify and reduce medical errors, measure, analyze, and track adverse patient events.

Refer to Tag A0286


3.)
have performance improvements to identify problem-prone areas from the data that had been collected for 20 months (January 2016-August of 2017).

Refer to Tag A0297


B.)

1.) maintain a sanitary environment in 9 of 9 areas on the North campus (Housekeeping, Linen room, patient nutrition room, kitchen, general storage, dumpster, patient rooms, rehabilitation room and clean supply storage) and 6 (Pharmacy, Nurses station, Rehabilitation and gym, patient room, crash cart and nurses medication room) of 6 area observed on the South campus.



2.) ensure the Infection Control Professional had specific infection control training prior to Directing the Infection Control program form January 2017 through August 2017


Refer to tag A 0748



3.) establish and maintain a process for identifying, and evaluating patients with Multi Drug Resistant Organisms and determine a safe effective process for isolation room assignments to ensure all patients safety from 8/212017 through 8/25/2017 survey.

Failure to ensure and maintain a sanitary environment put patients at risk for increased infections, re-infections or possible death. These deficient practices placed all patients at risk for the likelihood of harm, injury, or subsequent death.

Refer to A tag 0749 for additional information.


4.) ensure the Infection Control (IC) program was functional and incorporated into the hospital wide Quality Assessment Process Improvement (QAPI) program from January 2017 through August 2017.

Based on review and interview, the facility failed to;

1.)
take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are sustained for 20 out of 20 months (January 2016-August of 2017).

Refer to Tag A0283

2.)
provide an ongoing program that showed measurable improvement in indicators for which there is evidence that the program/process would identify and reduce medical errors, measure, analyze, and track adverse patient events.

Refer to Tag A0286


3.)
have performance improvements to identify problem-prone areas from the data that had been collected for 20 months (January 2016-August of 2017).

Refer to Tag A0297

Based on observation, interview and document review the facility failed to:

A. maintain a sanitary environment in 9 of 9 areas on the North campus (Housekeeping, Linen room, patient nutrition room, kitchen, general storage, dumpster, patient rooms, rehabilitation room and clean supply storage) and 6 (Pharmacy, Nurses station, Rehabilitation and gym, patient room, crash cart and nurses medication room) of 6 area observed on the South campus.


This deficient practice had the likelihood to effect all patients of the hospital.

Findings included:

On the morning of August 21, 2017 during the initial tour of the hospital's North campus, the following interviews and observation were made.

House keeping:
1. Housekeeper #7, was interviewed during the tour regarding when the patient privacy curtains were changed. She confirmed she did not change them and did not know when they were changed. She further confirmed she had not received training on a schedule or process for changing the privacy curtains out between patients. As far as she was aware the curtains were changed when the nurse told the evening house keeper to change them.

Privacy curtains in room 227 and 278 were visibly soiled with dark colored stains.

Interview with staff #2 confirmed there was no actual policy or schedule for changing the privacy curtains.


1) Rooms #225 and #226 shared one entrance. The room was designed like a "Y".

Room #225 and #226 shared a common shower and toilet area. An area of the wall, immediately prior to entering the bathroom had an area with torn plaster and a hole in the wall. The area was the size of a liquid hand sanitizer. In Room #225 a fold down seat made of wooded slats supported by a metal frame was observed with a white/gray stain on the top and bottom of the seat.

Room #226 was observed separated from #225 by a single privacy curtain. The curtain was observed with dark brown/black stains on the curtain. The curtain was observed with 3-4 holes in the mesh and a hooks caught in the mesh mid way between the top pf the mesh and the fabric of the curtain. The floors were heavily soiled with dark gray/black discoloration in the corners and the base boards were scratched, cracked,and stained. The patient room had a window that hinged inward and could be opened. The window ledge was visibly soled with loose gray black debris. The arms of the wooden furniture was heavily worn and the stain was no longer visible on the arms of the chairs. Two tall trash receptacles were locate at the apex between the two patients areas within the room. One was white for non biohazard trash and the other was red for bio hazard trash.


2) Room #227 and #228 were across the hall from the above mentioned rooms and the room design was the same. Room #227 was found in similar condition, however, the wall on the left side of the room where a patient would stay exhibited 6-7 long deep tracks that ran from the floor to near the ceiling. The sheet rock on this wall was deeply scared. The paint had been torn and the room had a sign left by the house keeper indicating the room had been sanitized and was ready for the next patient. When a surface is no longer in tact, it can not longer be completely sanitized. The window in the room hinged inward and upon opening the window the same dark gray debris was present. looking out the window trash could be seen behind the hedges below the window. Room #228 was observed to be occupied with a patient and examined.

Staff #3 was interviewed and asked what cold make such deep gouges in the wall in room #227 and she replied, "Probably the bed was too close to the wall when it was elevated for the staff to work with the patient and it cut into the wall".

Linen Room:

1) A rental air mattress was observed on the floor in a fabric case, in the clean linen storage room. This was confirmed by staff #2.

Staff #2, who gave the tour, stated, "He thought the representative who worked for the company that they rented there specialty mattresses's from had dropped it off in the clean linen room".

2) A Wound care Concepts bag, which contained a Vacuum Assisted wound closure device was observed on the counter in the clean linen room. This was confirmed by staff #2.

3) The drape was pulled back on one of the two linen carts to reveal linen hanging off the shelves. The bottom shelf held assorted blue scrubs for patient use. On of the scrub pants had fallen on to the floor with only a small portion still hanging on the lower shelf. This was confirmed by staff #2.


Patient nutrition room:

1) The ice maker, in the patient nutrition room, was observed with black mold below the upper surface where the ice was dispensed.

Staff #2, who gave the tour confirmed this finding.


Kitchen:

1) The refrigerator in the kitchen was opened and two (2) meal substitutes were observed with a date expiration of 8/21/2018. One of the other meals had been partially eaten and the lid replaced. The refrigerator was identified for patient meals only. The partially eaten tray did not have a patient room label on it.


General storage:

7) A cart was observed in a hall nook. The top of the cart was waist high and had a small stack of cups on it. The cups were marked with patient room numbers. The cups were not in a protective bag or box and were exposed to surrounding contaminates. Staff #2, who gave the tour, was questioned as to what the cups were used for and why were they left on the top of the cart. He replied "He didn't know and he would have to find out". No answer was provided.

8) The blood pressure bulb of a rolling blood pressure machine was observed with heavy dust on the bulb. This was confirmed by staff #2.

9) A hydroculator (a piece of equipment used to provide moist heat to a limb) was observed on the floor in a clean holding room was ready to use patient equipment. The hydroculator was not covered with a clean plastic cover indicating it had been sanitized and was ready for patient use. Staff #2 confirmed the hydroculator was no longer in use as evidence no longer supported its effectiveness. However it was stored with clean ready to use patient equipment.

Dumpster:

10) The facility leased space in a rehabilitation hospital and shared there dumpster on the grounds. Observation of the dumpster revealed a cinder block structure with three walls. An iron gate was open at the front of the dumpster. Behind the dumpster there was no wall for complete containment. The back of the dumpster containment was at the hospital ground level loading dock and exit doors. Behind the dumpster the area was full of equipment no longer in use. Examples: the hydroculator, over beds tables, potty chairs, a stainless steel cart loaded with steam table pans, 5 gallon buckets with lids attached, Three red heavy plastic biohazard containers that were full sealed and stacked on top of each other. Next to the three full biohazard containers were three empty containers turned upside down as if to drain.

Staff #3 and the Director of the contracted maintenance services could not determine if the biohazard containers were reused or not.



Patient Rooms:

11) Tape and tape residue was observed on all the wall switches and electrical outlets in each patient room. The surfaces were visible soiled with dark gray discoloration.


Rehabilitation room:

1) Beneath the sink in the rehabilitation department the surface was stained with a brown strain and a soiled cloth had been left below the sink on the floor.
2) An upper storage cabinet was observed with cleaning supplies and disinfectant stored next to the Speech pathologist supplies used for bed side swallow studies.
3. The walking surface of the parallel bars used in the rehabilitation room was worn and no longer able to be sanitized.



Clean supply storage room:

1) Observed in the clean supply storage were, two pink wash basins with supplies that were opened and partially used. A bottle of Peroxide had been opened and used but no date opened was found on the bottle, two (2) partially used rolls of Medipore tape were observed with dark brown stains on the end of each roll. A colostomy bag was observed in a second wash basin. The colostomy bag was not in a sanitary container.
2) The lower shelf on the stainless steel storage carts failed to have a splash guard that protected products on the lower shelf form being contaminated during sweeping and mopping.
3) Opened card board boxes were observed placed on the lower shelf.
4) A lower cabinet was opened to reveal an expired liquid hand soap. The expiration date was 4/2010.
5) A sink was located in the clean storage room. Water was observed splashed well outside the sink.
6) The Soap dispenser was observed with dark residue below the dispenser port.


Observations on the South Campus:

Pharmacy:

1) On the first shelf of an open lower cabinet, the following was observed: salt, pepper, canned soup, multiple empty Styrofoam cups with lids and straws stacked on top of the salt, pepper and soup.

1) Interview with staff #51, the supervising pharmacist, revealed the snacks were her's. Further questions regarding the collection of used but saved Styrofoam cups, lids and straws confirmed she, "Saved them for later use". Below this stash of snacks items was a pink wash basin with non labeled sheets of blister pack medication. Staff #51 confirmed they filled and sealed their own pill packs for blister pack use. However, these medications were not identified for any patient use. Staff #51 stated she found nothing wrong with snacks in the pharmacy because all the medications were in blister packs. She indicated the medications below the snack were not in use.

2) A small stainless steel refrigerator was observed with heavy streaking. The outside of the refrigerator looked like it needed cleaning. A sign on the door read "Food Only No Drugs". An interview with staff #51 confirmed, the food, "was for the pharmacy staff". The pharmacy staff were eating in the pharmacy.

3) The pharmacy had a hood used for mixing medication. There was no door or curtain which would protect the hood and mixing area from contamination from the refrigerator and employee food in the very small pharmacy.








B. ensure the Infection Control Professional had specific infection control training prior to Directing the Infection Control program form January 2017 through August 2017


Refer to tag A 0748



C. establish and maintain a process for identifying, and evaluating patients with Multi Drug Resistant Organisms and determine a safe effective process for isolation room assignments to ensure all patients safety from 8/212017 through 8/25/2017 survey.

Failure to ensure and maintain a sanitary environment put patients at risk for increased infections, re-infections or possible death. These deficient practices placed all patients at risk for the likelihood of harm, injury, or subsequent death.

Refer to A tag 0749 for additional information.


D.

ensure the Infection Control (IC) program was functional and incorporated into the hospital wide Quality Assessment Process Improvement (QAPI) program from January 2017 through August 2017.


32143

A tour of the south campus was performed on 8/25/17. The finding are listed as follows;

1.) The front nurses station.

A.) The front nurse's station desk was made of a wood substance. The wood laminate was worn and bare wood was exposed. The desk was not properly sealed and unable to be cleaned appropriately.

2.) The rehabilitation room and gym.

A.) a cabinet in the rehab room was found to have cleaning supplies and patient linen stored together.

B.) The Hydrocollator was a metal container used as a thermostatically controlled water bath for placing bentonite-filled cloth heating pads. The device was found on and full of heating pads. The top of the Hydrocollator was rusted around the knob and inside was found to have rust and hard water mineral build up on the walls. The cloth pads in the Hydrocollator were found soiled.

C.) The wooden base of the parallel bars in the rehab room was found to be soiled with dust and hair. The wood base was worn and bare wood was exposed making it difficult to properly clean.

Staff #38 confirmed the findings. Staff #38 was able to find a cleaning schedule for the Hydrocollator but was only cleaning it once a month. According to the Manufacturer guidelines, "clean and drain the tank (every two weeks). Failure to properly maintain the unit will cause premature wear and will void the warranty. Remove all deposits from interior surfaces and parts. The deposits are concentrations of minerals that will allow rusting to begin. If allowed to accumulate on the heating element, these deposits will lower the efficiency of the element and increase the power consumption of the unit. However, exercise extreme care if cleaning element or thermostat(s). These components can be easily damaged without proper care or caution. If you suspect that you have "hard water", you may need to change the water and clean the unit more frequently. Salt deposits are an indication of hard water that will eventually cause rust."

3.) The nurse's desk in the middle of the hall was found to have laminate strips chipped and missing with exposed wood. Exposed wood is porous and difficult to disinfect.

4.) The following items were found in patient room 651. The room had been designated as a room that had been terminally cleaned between patients and was ready for a new patient.

A.) The biohazard trash can was found to be soiled with dust and hair on the lid. Unidentified spills were noted on the sides of the trash can.

B.) The bedside table was found to be soiled with dust and the top was missing laminate with exposed bare wood particle board.

C.) The lounge chair was found to have worn wooden arm rest. The bare wood was exposed. The sides of the chair were soiled with unidentified substances. The back of the lounge chair was heavily soiled with dust and dirt. There was a black unidentified substance on the foot rest covered in hair and dust. The foot rest was worn, torn in several places, stuffing hanging out, and wood exposed. The foot rest was raised and a heavy film of dust, hair, dried food crumbs, and a used Kleenex was found underneath.

D.) The main door was chipped up and missing laminate exposing bare wood.

E.) The wooden base holding the sink was found to be chipped and splintered with exposed wood present. The bathroom fixture was found to have a broken lens over the sink. The metal paper towel holder was soiled on top with dust and hair.

F.) In the patient bathroom the shower enclosure was not installed properly. A gap was found between the enclosure and the faucet fixture allowing water to run behind the shower enclosure.

G.) The toilet had a metal sprayer on the flush body. The sprayer head was found to be heavily coated in mineral deposits. The sprayer was unable to be cleaned properly. The base of the toilet was found to be soiled with a buildup of dried urine.

H.) Behind the toilet the floor was found to be coated in a yellow/orange substance, dirt, and hair.

I.) A pad was removed from the bed and a hole was found on the fitted sheet. The bed was found to have a soiled pillow case. Brown and black hairs were found on the pillow case. The top sheet was soiled with unidentifiable stains. The mattress was found to be soiled underneath with unidentifiable substance. The mattress was found to be worn and soiled, on the top, at the corners with a brown substance. The head board and foot board was soiled with dust and hair. The bedside rail and controls were found to be soiled with dirt, dust and hair.

J.) The patient bedside table was found to be soiled with dust and old tape.

K.) The light fixture above the bed was found to have dried, splattered unidentified substance on the lens. The ceiling above the bed had a brown splattered substance. The fire sprinkler in the ceiling was dusty and soiled.

L.) The patient bedside table was found to be soiled. The drawer was pulled out and inside the drawer track was heavily soiled with dried food particles, dust, and hair.

5.) The following items were found on the crash cart in the hallway by the second nurse's station;
A. The tracheal Tube was hanging off of the side of the crash cart. The tube expired on 1/2017. An open battery charger and opened exposed batteries were touching patient supplies in the crash cart. Opened empty packages were found in the supplies of the crash cart. The items were not discarded in the trash.

6.) The following items were in the nurse's medication room;

A.) The sharps container was full and currently being used.

B.) A wall telephone was found to have an extra-long cord. The cord was lying in the trash can on top of a hazardous bag and trash. The walls were dirty and soiled. Sheet rock was exposed next to the trash can.

C.) The medication pill crusher was soiled with dust and the paint was worn off exposing the metal.

D.) A drug handbook was found with mildewed pages sitting next to patient medications.

E.) A device called a CACTUS was found sitting on a small refrigerator. The device is used to discard unwanted medications or pharmaceutical waste. The device was soiled with dust, hair, and a copious brown substance in the top of the drain.

F.) A small medication refrigerator was found sitting on the floor of the medication room. The outside of the refrigerator and the top of the refrigerator was soiled with dust, hair, and unidentifiable dried white particles. The inside of the refrigerator was soiled with dust and hair. Three patient IV bags were in the refrigerator lying on the soiled surface. A patient IV bag, ready for use, was found to have a long black hair stuck to the sticker of the medication bag. The hair was wrapped around the IV bag.

G.) A review of the description of the Pyxis Medstation revealed, "The Pyxis MedStation (Trademark) automated medication dispensing system supports decentralized medication management with various features for safety and efficiency. The system helps accurately dispense medication, while supporting pharmacy workflows." The Pyxis had 2 upright cabinets with a glass front and shelves that are locked. It has a refrigerated refrigerator attached that also locked. There was a screen and key pad. The base of the Pyxis is drawers with medications. The user must type in the medication they want and a code to unlock the device.

The Pyxis was visibly soiled on the outside with dust, hair, and dried spilled substances. The Pyxis was next to a wall that had missing sheet rock and was soiled with dirt, dust, and pen marks. The key board was heavily soiled with dirt and dust. The keyboard was covered by a piece of plastic to protect the keys. It had been taped down to the base of the computer with nylon tape that was soiled with dirt and hair. The plastic cover was torn in multiple areas and heavily soiled with dirt and dust. The ends of the plastic were black in some spots. The base holding the keyboard was heavily soiled with dust and trash was found behind it. Behind the keyboard a blue open container was found to have paper rolls for the Pyxis and an instruction manual covered in a heavy dust.

The Pyxis was heavily soiled on the outside and noticed to be soiled on the inside. The pharmacists was asked to open the cabinet to view the inside to determine the cleanliness of the cabinet. The pharmacist squatted down and placed both hands on the dirty floor. The pharmacist then stood up and typed on the Pyxis keyboard, opened the cabinet, and pulled out medication bins without washing her hands after touching the soiled and dirty floor.
The Pyxis was heavily soiled on the outside and noticed to be soiled on the inside with dust, hair, and dried spilled substances. Inside the cabinet were clear plastic bins that held patient medications. The bins were soiled with dust and dirt.

H.) Under a cabinet a large open container of normal saline flushes were found. The flushes were exposed to shipping boxes. The shipping boxes may have been exposed to outside contaminates. The cabinet was heavily soiled with dust, dirt, and hair. The cabinet doors were found heavily soiled with a dried brown dripping substance.

I.) Loose vacutainers were found in a gray plastic pan. The bottom of the pan and vacutainers were soiled with dust, dirt, and hair.

Staff #4 was witness to the findings and confirmed the findings. Staff #4 stated, "I just don't know what to say and shook her head."

Based on review and interviews the Governing Body failed to;

A.) ensure the facility had an updated policy and procedure specific to the facility.

B.) ensure the grievance process was followed through the Governing Body or designated Grievance Committee.

C.) ensure the complaint/grievance are addressed in a timely manner and worked through the Quality Assessment Performance Improvement (QAPI) process.

D.) ensure the staff had training and a clear understanding of a complaint/grievance process.


Review of the Complaint/Grievance log revealed there was no complaint or grievance concerning patient #26. Patient #26's daughter stated she had made multiple complaints to the nursing staff on general care of her mother and to staff #37 concerning discharge to a rehabilitation hospital and lack of therapy.

Review of the policy and procedure "Grievance Resolution Process for Patients" revealed the policy was last revised July 6, 2011. The policy is a corporate policy and not specific for this hospital. Staff #1 confirmed cooperate office was in Pennsylvania.

The policy and procedure "Grievance Resolution Process for Patients" stated, "Patients may request of any staff member (either verbally or in writing) that the grievance resolution process be initiated. If the patient is unable to communicate their complaint, a patient liaison will be provided to assist. The staff member receiving the request will immediately notify their supervisor as well as the facility risk manager (or designee) and complete a Critical Incident Report if one has not been initiated."

Interview with staff #3 and #36 on 8/24/17. Staff #36 stated she was part of the liaison team and was assigned patient room numbers that she would be responsible for. Staff #36 stated that she and the other managers had assigned room numbers to handle complaints or problems. Staff #36 stated she goes to her assigned patient rooms daily and checks on the patients. Staff #36 stated' "If there is a complaint I will fill out a form and then I pass the complaints on to whomever the complaint is about. If it's a nursing issue, I go to the charge nurse, if it's a house cleaning issue than I go to housekeeping." Staff #36 confirmed once she has handed the complaint off she is done with the issue unless people just keep complaining about it. Staff #36 stated they have meetings in the mornings and talk about patient issues. Staff #36 confirmed she has not taken the complaints to the risk manager who was responsible for complaints and grievances. Staff #36 stated she has had no formal training on complaints and grievances. Staff #36 stated the definition of a grievance was a complaint that just keeps going on. "It just depends on if the complaint is continuous."

Staff #3 agreed that this is probably why she had only 6 complaints on her list for the last 8 months. Staff #3 was not aware of when a complaint became a grievance without the patient requesting it.


The policy and procedure "Grievance Resolution Process for Patients" stated the risk manager refers the grievance to the Grievance Committee which will meet and provide written documentation to the patient within five business days from the date the grievance request was received."


Interview with staff #3 on 8/24/17 revealed there were no meeting minutes or proof there was an organized Grievance Committee. Staff #3 stated that the grievances have not been followed in the QAPI process.


Review of the Complaint and Grievance log revealed only 5 complaints. The top of the log stated, "North and South 2017." The complaints were as follows;

Review of the Complaint and Grievance log revealed patient #26 had no documented complaints or grievances.

1.) The first complaint, patient #14, was taken on 1/8/17. The complaint stated, "c/o skin tear to hand after transfer for procedure." The complaint was not charted as resolved on the list until 1/31/17. There was no further information on the incident or any details of the complaint or resolution.

2.) The second complaint, patient #15, was taken on 3/10/17 concerning a nurse being unprofessional and was resolved on 3/10/17.

3.) The third complaint, patient #29, was taken on 3/6/17 concerning nurse not being helpful or caring and was not resolved until 3/10/17. There was no further information on the investigation.

4.) The fourth complaint, patient #27, was taken on 3/6/17 the patient complained of "not enough therapy, nursing not helpful and nursing not helping with food tray." There is no details of an investigation and the complaint is not marked as resolved. In the resolution box it stated, "met with sister several times." No further information.

5.) The fifth complaint, patient #28, was taken on 5/1/17. Patient complained of "room being dirty, not enough therapy, uncaring nursing staff." Under resolution section of the log stated, "still working with family PT resolved." There was no details on the complaint.

There was no evidence provided or found that the last two complaints were ever resolved or documented that it was in a grievance investigation.

Based on review and interview the Governing body failed to ensure the hospital had trained staff to assist with the grievance process and followed the set time frames to resolve the patient issues.

Review of the policy and procedure "Grievance Resolution Process for Patients" revealed the policy was last revised July 6, 2011. The policy is a corporate policy and not specific for this hospital. Staff #1 confirmed cooperate office was in Pennsylvania.

The policy and procedure "Grievance Resolution Process for Patients" stated, "Patients may request of any staff member (either verbally or in writing) that the grievance resolution process be initiated. If the patient is unable to communicate their complaint, a patient liaison will be provided to assist. The staff member receiving the request will immediately notify their supervisor as well as the facility risk manager (or designee) and complete a Critical Incident Report if one has not been initiated.

The risk manager refers the grievance to the Grievance Review Committee which will meet and provide written documentation to the patient within five business days from the date the grievance request was received."

Interview with staff #3 and #36 on 8/24/17. Staff #36 stated she was part of the liaison team and was assigned patient room numbers that she would be responsible for. Staff #36 stated that she and the other managers had assigned room numbers to handle complaints or problems. Staff #36 stated she goes to her assigned patient rooms daily and checks on the patients. Staff #36 stated' "If there is a complaint I will fill out a form and then I pass the complaints on to whomever the complaint is about. If it's a nursing issue, I go to the charge nurse, if it's a house cleaning issue than I go to housekeeping." Staff #36 confirmed once she has handed the complaint off she is done with the issue unless people just keep complaining about it. Staff #36 stated they have meetings in the mornings and talk about patient issues. Staff #36 confirmed she has not taken the complaints to the risk manager who was responsible for complaints and grievances. Staff #36 stated she has had no formal training on complaints and grievances. Staff #36 stated the definition of a grievance was a complaint that just keeps going on. "It just depends on if the complaint is continuous."
Staff #3 agreed that this is probably why she had only 5 complaints on her list for the last 8 months. Staff #3 was not aware of when a complaint became a grievance without the patient requesting it.

Review of the Complaint and Grievance log revealed only 5 complaints. The top of the log stated, "North and South 2017." The complaints were as follows;

1.) The first complaint was taken on 1/8/17. The complaint stated, "c/o skin tear to hand after transfer for procedure." The complaint was not charted as resolved on the list until 1/31/17. There was no further information on the incident or any details of the complaint or resolution.

2.) The second complaint was taken on 3/10/17 concerning a nurse being unprofessional and was resolved on 3/10/17.

3.) The third complaint was taken on 3/6/17 concerning nurse not being helpful or caring and was not resolved until 3/10/17. There was no further information on the investigation.

4.) The fourth complaint was taken on 3/6/17 the patient complained of "not enough therapy, nursing not helpful and nursing not helping with food tray." There is no details of an investigation and the complaint is not marked as resolved. In the resolution box it stated, "met with sister several times." No further information.

5.) The fifth complaint was taken on 5/1/17. Patient complained of "room being dirty, not enough therapy, uncaring nursing staff." Under resolution section of the log stated, "still working with family PT resolved." There was no details on the complaint.

There was no evidence provided or found that the last two complaints were ever resolved. An unresolved complaint would be processed as a grievance. There was no documentation that it was in a grievance investigation nor within the 5 day timeline.

Interview with staff #3 on 8/24/17 revealed there were no meeting minutes or proof there was an organized Grievance Committee.

Based on record review and interview, the facility failed to implement performance improvement activities, measure its success, and track performance to ensure that improvements are sustained for 20 out of 20 months (January 2016-August of 2017).

Review of the QAPI scorecard for January- April 2017 revealed the data was out of range on restraints, ventilator wean rates, overall satisfaction, and delinquency rates on completions of Discharge Summary. There was no PI projects found to address these ongoing issues. Review of the data revealed the QAPI program was not following contracted services; Laboratory and Radiology.

Review of the Quality Assessment Performance Improvement (QAPI) for 2016 and 2017 from January -August revealed the only Performance Improvements (PI) found, addressed hand hygiene and falls for September of 2016. The PI projects for June 2017 and July 2017 consisted of the following;

1.) Dated 6/2017 "HR Education files revealed deficiencies with New Hire Competencies being completed and returned."

Under analyze situation: stated, "Impact on important function of care of patients: N/A. Identify needed team: HR Director, Nurse Managers, CNO." There can be a great impact on patient care if a nurse does not have training or competencies to administer care with proper techniques. Possible patient harm or death may occur. Their HR director was no longer employed at the facility and a HR director from corporate had recently come to the facility to assess the problems. The CNO and managers had not worked to update and bring current the employee files as of 8/21/17.

2.) "High number of patients in restraints and high number." Date initiated 6/29/17. Under analyze situation: stated, "Impact on important function of care of patients:" was blank. Identified needed team CNO, Nurse Managers, Director of Quality, Charge Nurses. There was no documentation on who was on this team, what was their objective, or what time frame the PI project would be reevaluated by the team for further review or change in process.

The action plan stated, "Nurse Managers or designee will audit all restraint charts daily to verify proper documentation by nurses and physician orders. All patients in restraints will be discussed in Flash meeting to evaluate need for restraints and discuss alternatives." There was no documentation of the Flash meetings or what was discussed.

Staff #3 revealed the facility was doing 100% chart audits for restraints to ensure the restraints were properly documented, ordered, and assessed. Staff #3 stated the charge nurses on each shift were to audit the charts. Review of the audit forms revealed patient #6 was on the audit tool for 7/28/17. On the section for "care plan updated" the nurse put in a check mark. Under restraints "Doc. /Order" the nurse put in N/A. Patient #6 was documented in wrist restraint with an order on this date. Staff #3 was asked if she had compiled any of this data to see what the needs or education issues were and she stated, "Well we look at it and report it in the flash meetings but there is no true breakdown."

Interview with staff #3 revealed there had been no patient death in restraints or 24-48 hours after restraints. Staff #3 stated there is no log for patients in restraints or death in restraints. Staff #3 stated they had started listing patient in restraints on a list with blood patients so they could audit the charts as part of their plan of corrections from the last survey but there was no official log.

Interview with staff #17 RN Nurse Manager on 8/23/17 stated that she was given training on the policy but there was no hands on training for the restraints. Staff #17 confirmed there was no check-off for the skill. Staff #17 reported that if she had to write the order for the restraint she just filled it all out and the doctor would sign it when he/she came in. Staff #17 reported she thought it was within 24 hours on the initial but was not sure on the daily time frame.

There had been no meetings to assign a PI team for the PI projects in place. There was no list on who was participating in the PI teams and what the plan and expectations are for this project. Staff #3 confirmed the findings.
Staff #3 stated she was no longer the QAPI director and that position had been turned over to staff #4. Staff #4 had signed a job description on 7/24/17 but was still in the training process.

Based on review and interview the facility failed to provide an ongoing program that showed measurable improvement in indicators for which there is evidence that the program/process would identify and reduce medical errors, measure, analyze, and track adverse patient events.


Review of the QAPI scorecard for January- April 2017 revealed the data was out of range on restraints, ventilator wean rates, overall satisfaction, and delinquency rates on completions of Discharge Summary. There was no PI projects found to address these ongoing issues.

Review of QAPI meeting for May 2017 does not address any specific PI projects are patient safety items including: tracking medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital.

Review of the QAPI meeting for August 11, 2017 revealed the EOC Corporate officer was at the facility to check on the EOC status. The minutes stated, " Large list of items to be fixed have been received from _____Corporate EOC Officer. This will be given to maintenance department on both campuses for repairs. Will need to follow up regarding status of work orders. Will report as repairs are completed to QAPI and GB." There was no assignments, PI project or follow through for the patient safety issues. Staff #1 was asked to provide the work orders three times and failed to do so.

Review of the QAPI meeting for August 11, 2017 revealed that weekly QAPI meetings were going to be conducted starting 6/29/17 with feedback and data collected. There has been data collected but there is no evidence of a analysis on the scope of the problems or a plan.

Review of the (QAPI) program revealed there was not a clear understanding on who was the Patient Safety Officer or Risk Manager. The facility has not done a root cause analysis (RCA) for over a year. An Interview was conducted with staff #1 and #3 on 8/23/17. Staff #3 stated she was trying to do the jobs but had no official training and had not signed a job description for those positions. Staff #1 confirmed the findings and confirmed there was no job descriptions.

Based on review and interview, the facility failed to have performance improvements to identify problem-prone areas from the data that had been collected for 20 months (January 2016-August of 2017).


Review of the QAPI scorecard for January- April 2017 revealed the data was out of range on restraints, ventilator wean rates, overall satisfaction, and delinquency rates on completions of Discharge Summary. There was no PI projects found to address these ongoing issues. Review of the data revealed the QAPI program was not following contracted services; Laboratory and Radiology.

Review of the Quality Assessment Performance Improvement (QAPI) for 2016 and 2017 from January -August revealed the only Performance Improvements (PI) found, addressed hand hygiene and falls for September of 2016. The PI projects for June 2017 and July 2017 consisted of the following;

1.) Dated 6/2017 "HR Education files revealed deficiencies with New Hire Competencies being completed and returned."

Under analyze situation: stated, "Impact on important function of care of patients: N/A. Identify needed team: HR Director, Nurse Managers, CNO." There can be a great impact on patient care if a nurse does not have training or competencies to administer care and techniques. Possible patient harm or death may occur. There HR director was no longer employed at the facility and a HR director from corporate had recently come to the facility to assess the problems. The CNO and managers had not worked to the employee files as of 8/21/17.

2.) "High number of patients in restraints and high number." Date initiated 6/29/17. Under analyze situation: stated, "Impact on important function of care of patients:" was blank. Identified needed team CNO, Nurse Managers, Director of Quality, Charge Nurses. There was no documentation on who was on this team, what was their objective, or what time frame the PI project would be reevaluated by the team for further review or change in process.

The action plan stated, "Nurse Managers or designee will audit all restraint charts daily to verify proper documentation by nurses and physician orders. All patients in restraints will be discussed in Flash meeting to evaluate need for restraints and discuss alternatives." There was no documentation of the Flash meetings or what was discussed.

Staff #3 revealed the facility was doing 100% chart audits for restraints to ensure the restraints were properly documented, ordered, and assessed. Staff #3 stated the charge nurses on each shift were to audit the charts. Review of the audit forms revealed patient #6 was on the audit tool for 7/28/17. On the section for "care plan updated" the nurse put in a check mark. Under restraints "Doc. /Order" the nurse put in N/A. Patient #6 was documented in wrist restraint with an order on this date. Staff #3 was asked if she had complied any of this data to see what the needs or education issues were and she stated, "Well we look at it and report it in the flash meetings but there is no true breakdown."

Interview with staff #3 revealed there has been no patient death in restraints or 24-48 hours after restraints. Staff #3 stated there is no log for patients in restraints or death in restraints. Staff #3 stated they had started listing patient in restraints on a list with blood patients so they could audit the charts as part of their plan of corrections from the last survey but there was no official log.

Interview with staff #17 RN Nurse Manager on 8/23/17 stated that she was given training on the policy but there was no hands on training for the restraints. Staff #17 confirmed there was no check off for the skill. Staff #17 reported that if she had to write the order for the restraint she just filled it all out and the doctor would sign it when he/she came in. Staff #17 reported she thought it was within 24 hours on the initial but was not sure on the daily time frame.

There had been no meetings to assign a PI team for the PI projects in place. There was no list on who was participating in the PI teams and what the plan and expectations are for this project. Staff #3 confirmed the findings.

Staff #3 stated she was no longer the QAPI director and that position had been turned over to staff #4. Staff #4 had signed a job description on 7/24/17 but was still in the training process.

Based on observation, interview and document review the facility failed to ensure the Infection Control Professional had specific infection control training prior to Directing the Infection Control program form January 2017 through August 2017



This deficient practice had the likelihood to effect all patients of the hospital.


Findings included:


On the morning of 8/22/2017, in the conference room an interview with staff #3 confirmed she was the acting infection control professional (ICP). A review of staff #3's employee file revealed she did not have a signed job description to serve as the ICP. Further review revealed there was no evidence in her employee file to indicate staff #3 had received IC training sufficient to direct the IC program.

A review of the "Infection Control Program", last updated 1/22/2015, indicated "Policies and Procedures are based in the following":

APIC (Association for Professionals in Infection Control)
SHEA (Society for Healthcare Epidemiology of America)
CDC (Centers for Disease Control)
State Regulations
OSHA (Occupational Safety and Health Administration)
CMS (Centers for Medicare and Medicaid Service)
Joint Commission Requirements.

Further interview with Staff #3 confirmed she had completed online modules offered from her corporate offices, but did not know if they were provided through any of the above listed organizations that the hospitals Policies and Procedures were based on. Further she could not provide evidence she competed the training.

Staff #2 was asked to provide the written Infection Control Program she was using. Staff #3 provided a written document that was titled Infection Prevention and Control Plan, last reviewed 1/22/2015". When asked if the document provided was the most current staff #3 confirmed, it was.

The facility had no documentation that staff #3 had received Infection Control training from a nationally recognized infection control organization, had not signed a job description indicating staff #3 was aware of the requirements and responsibilities of the IC professional, and had provided staff #3 with an outdated Infection Prevention and Control Plan as guidance to implement the Infection Control program for the hospital.


The facility did not have a qualified ICP.

Based on observation, interview and document review the facility failed to establish and maintain a process for identifying, and evaluating patients with Multi Drug Resistant Organisms and determine a safe effective process for isolation room assignments to ensure all patients safety from 8/212017 through 8/25/2017 survey.

Failure to ensure and maintain a sanitary environment put patients at risk for, infections, re-infections, or possible death. These deficient practices placed all patients at risk for the likelihood of harm, injury, or subsequent death.



Findings included:

On 8/21/2017, on the North campus, the following infection control concerns were identified:

On the afternoon of 8/21/2017, in the conference room, the medical record (MR) for patient's (Pt/pt)#10 and #11 were reviewed. Pt #11 had a open wound. Pt #11 was in isolation with positive MRSA (Methocillin Resistant Staph Aurus). A privacy curtain separated pt #11 and her room mate.

Review of patient #10's MR revealed: Patient #10 was a 65 year old woman who had several conditions that complicated her ability to fight infection. She was diabetic, had muscular dystrophy and was bed bound, had heart disease with heart failure, and had a non-healing wound.

Review of Patient #10's chart from current admission showed that she was admitted to Long Term Acute hospital on 8-15-2017. The History and Physical (H&P) dictated on 8/16/2017 indicated the surgical debridement of patient's wound occurred on 8-10-2017 in the acute hospital. The H&P did not mention any active MRSA infections. The H&P did not mention any positive blood cultures or address the patient receiving Vancomycin for positive blood cultures. The Discharge Summary from 8-22-2017 did not mention treatment for MRSA or positive blood cultures.

Review of the Admission Orders did not reveal an order or reason for the patient to be placed in isolation precautions. Admission medication orders included "Clindamycin 300 mg PO BID" (300 milligrams by mouth twice a day) and "PICC Line" (peripherally inserted central catheter is an IV line that is inserted into a deep vein and usually used for patient with poor shallow veins or for long term IV medication administration). The order for Clindamycin did not give the indication (reason) for the antibiotic. Chart review showed that no PICC line was ever placed.

An interview was conducted with Staff #3 on 8-22-2017. Staff #3 stated, she did not know why the patient was on oral Clindamycin. Staff #3 was not able to locate in the chart any information such as lab results and cultures concerning an active MRSA infection.

Patient #10 was placed in a room with a patient #11, who had an active MRSA infection.



Staff #3 was interviewed in the late morning, of 8/23/2017. She confirmed, she was on vacation and was not in the house when patient #11 and patient #10 were placed in the same room. Staff #3 confirmed, she was the acting Infection Control Nurse. Staff #3 was asked if she had a method for identifying and tracking patients with infections that required isolation. She indicated she used the daily nurses patient roster which told each patient and their diagnosis. The nurses roster for 8/23/2017 was reviewed with staff #3 and it was brought to her attention that the list did not capture patients whose diagnosis changed mid shift, related to lab results that came in late or when the nurse failed to update the patient roster and diagnosis list. She confirmed she was not aware, the nurse's patient roster was incomplete and that patients with infections requiring antibiotics and or isolation were not captured. She confirmed, she didn't have an on-going Infection Control record where each patient's infection was logged or tracked. She tallied the patients with infections at the end of each month.


On the afternoon of 8/23/2017 in the conference room with staff #1, #2 and the corporate nurse were present for interviews. The leadership was asked how were patient room assignments determined? Staff #2 indicated staff #3 made the room assignments.

Staff #2 was reminded that staff #3 was on vacation and not in the building when patient #10 and patient #11 were placed in the same room. Staff #2 then indicated the floor nurses knew how to co-habitate patients.

Staff #2 was then asked who had the final say where patients were placed and who they were placed with. Staff #2 confirmed, He did , as the Chief Nursing Officer.

An interview with Registered Nurse, staff #31 indicated, "she knew how put the right patient in the right room", however, she could not explain the process. Staff #31 couldn't remember if she had been in-services regarding choosing room for isolation patients.


A review of the policy , "MDRO (Multi drug Resistant Organism) Contact Isolation" revealed,
Policy:
"19.2.1 Patients colonized or infected with MDRO will be evaluated on individual basis for containability of infective substance and mental-cognitive status.
19.2.2 Patients identified with MDRO will be cohorted or placed in a private room. Otherwise, place patient in a room with another patient who:
19.2.2.1 is not immuno-compromised, (cancer, getting chemotherapy, HIV (Human Immuno Virus) positive, autoimmune disorder, etc)
19.2.2.2 does not have tubes, (Indwelling Foley Catheter, suprapubic catheter, IV (Intravenous) access, Peg, (Percutanious gastrostomy), NF (Naso gastric) tracheostomy, etc).
19.2.2.3 does not have open wounds".

A review of the Infection Control program for the facility revealed the program had not been approved by the Governing Body since 2015. The infection Control program had not been updated.


Staff #2 and staff #1 were not familiar with their hospitals policy and had not followed the policy. Staff #1 and #2 had not educated there staff on the above mentioned policy. Both staff #2 and staff #3 indicated there "should be" a physician's order for isolation. Staff #1 confirmed they did not have a clear method of determining isolation and who would be co-habitated when infections were present that required isolation. Staff #1, #2, and #3 were made aware their Infection Control Plan had not been approved by the Governing Body since 2015.


Patient #10, in an already immuno-compromised condition, had an open wound, IV access, and co-morbidities that had the likelihood to place this patient at risk of re-infection when she was co-habited with pt #11.

The hospitals leadership demonstrated a lack of knowledge related to the hospitals Infection Control Plan, as well as, policies and procedures. The nursing department demonstrated a lack of initiative in advocating for patient health and safety.


This deficient practice posed an Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequently death.