HospitalInspections.org

Based on review of Quality Assurance/Performance Improvement (QAPI) records, governing body minutes, and staff interview, the hospital failed to meet the requirements for the Condition of Participation for Quality Assurance/Performance Improvement as evidenced by:

1) Failure to ensure the QAPI program was an ongoing program that showed measurable improvement in indicators as evidenced by failing to analyze the data collected to improve performance and processes of care and identify opportunities for improvement (see findings at A0273);

2) Failure to focus performance improvement activities on high-risk, high-volume or problem prone areas as evidenced by failing to develop and implement quality indicators to track, analyze, and trend the high incidents of PICC ( Peripherally Inserted Central Catheter) lines dislodged and no longer secured in the patient for 14 out of 58 incidents reviewed in the last 10 months at the hospital's main campus (see findings at A0283);

3) Failure to accurately collect medication error data to analyze for quality assessment and performance improvement for 1 (offsite) of 2 (main, offsite) campuses reviewed for medication errors (see findings at A0286);

4) Failure to conduct P.I. (Performance Improvement) projects as part of their QAPI program. This failed practice was evidenced by no documented P.I. projects in their QAPI program (see findings at A0297);

5) Failure to ensure the QAPI program included all hospital departments and services as evidenced by failing to include contracted services in the QAPI program (see findings at A0308).

Based on record reviews, contract reviews and interview the hospital failed to ensure the hospital's contracted services were performed to allow the hospital to demonstrate independent compliance with Conditions of Participation. This was evidenced by Promise Hospital of Baton Rouge signing a contract to purchase, and then purchasing code blue services from Hospital "A" for services at the hospital's main campus. Findings:

Review of the "Lease" contract including "Attachment A", dated 10/15/02, and presented to the surveyor as the most current agreement between Promise Hospital of Baton Rouge (Main Campus) long term acute care hospital and acute care host Hospital "A", revealed Promise Hospital of Baton Rouge (Main Campus) is purchasing code coverage and emergency services from acute care Hospital "A".
This agreement further stipulated that acute care hospital "A" will respond to any code blue or emergency situations in long term care hospital Promise Hospital of Baton Rouge (Main Campus) and will provide physician and other professional staff to be available on-call in the emergency department to provide cardio-pulmonary arrest and Code Blue services to Promise Hospital of Baton Rouge.
Review of the hospital's Code Blue log from January to October 2013 revealed 11 code blue events were documented from January to August and were responded to by staff from Hospital "A".

Review of the hospital's Rapid Response Team log from January to September 2013 revealed there were 12 Rapid Response Team events that were responded to by staff from Hospital "A".

In an interview on 11/05/13 at 1:50 p.m., S1DON (Director of Nursing) stated the Rapid Response Team was called when the nurse had a "bad feeling" about the patient. S1DON stated the Rapid Response Team was an ICU (Intensive Care Unit) Nurse and the House Supervisor, both from Hospital "A". S1DON stated the Code Blue Team was the Emergency Department Physician, ICU nurse, House Supervisor, and a Respiratory Therapist all staff from Hospital "A". S1DON verified the hospital did not have a contract with the Emergency Department physician group at Hospital "A".

In an interview on 11/05/13 at 2:20 p.m., S25DON at Hospital "A" confirmed the hospital's Code Blue Team responded to Code Blue events in Promise Hospital of Baton Rouge. S25DON at Hospital "A" stated the Code Blue Team consisted of the Emergency Room (ER) Physician, an ER nurse, the House Supervisor, an ICU nurse, and a Respiratory Therapist. She stated the Rapid Response Team of Hospital "A" also responded to situations in Promise Hospital of Baton Rouge and consisted of a Respiratory Therapist, the House Supervisor, and an ICU nurse.

26351

Based on record review and interview the hospital failed to ensure effective implementation of the grievance process for prompt resolution of patients' grievances as evidenced by failing to determine correctly whether a patient concerns were complaints or grievances for 6 of 6 complaints reviewed (R1, R2, R3, R4, R5, R6).

Findings:

Review of the hospital policy titled, "Complaint/Grievance Process", number RSK 002, approved date of 04/04/05 and provided as current policy by S1DON (Director of Nursing) revealed in part the following: Definition: Complaint: A written or verbal concern or objection from a patient or the patient's designated representative regarding the quality or appropriateness of patient care as well as other concerns that can be effectively addressed and resolved by informal means. Generally a complaint may be resolved quickly by the staff member receiving the complaint Grievance: Written or verbal requests by a patient or designated representative to have Promise Hospital formally review the patient's concern or objection about the quality or appropriateness of patient care or other concerns. Generally a grievance would require an investigation and/or may require management level personnel to resolve the grievance. This concern cannot be resolved promptly by staff present at the time of the occurrence. A written complaint that is not easily resolved is considered a grievance, whether from an inpatient, outpatient, released/discharged patient or their representative regarding the patient care provided, abuse, or neglect, or the hospital's compliance with standards and regulations...

Review of the Complaint Log at the main campus of the hospital from January 2013 to present (November 5, 2013) revealed there were 2 complaints documented for #R5 and #R6.

Review of the "Complaint Report"dated 05/01/13 for #R5 revealed the patient complained to S30RN PI Coordinator that a CNA (Certified Nursing Assistant) had been rude and abrupt toward him, acted like she did not want to help him, and the CNA had a bad attitude. The report also revealed the patient was concerned the CNA would treat him worse if her reported her. Review of the form revealed the action taken was, "Investigated and discussed with person with the complaint, Reported to Department Manager." Attached to the form was an, "Employee Counseling Form" dated 05/03/13 for the CNA involved in the patient's complaint.

Review of the "General Occurrence Report" dated 03/18/13 for #R6 revealed the patient and his wife complained the call light was not being responded to in a timely manner, having to wait a long time for assistance with the urinal, and not being kept up to date on the patient's status and discharge plans. Further review of the report revealed the patient's complaints were voiced to the staff on the night shift on 03/17/13 and the form was documented by S30RN PI Coordinator on 03/18/13.

There was no documented evidence that either complaint was handled as a grievance. There was no documented evidence of a written response to the complainants.

In an interview on 11/05/13 at 2:55 p.m., S30RN PI Coordinator verified she had investigated and documented the complaints for patients #R5 and #R6. S30RN PI Coordinator stated a complaint was, "anything that could be handled through the chain of command." S30RN PI Coordinator verified the complaints from patients #R5 and #R6 were handled as complaints. S30RN PI Coordinator reviewed the complaint for patient #R6 and verified the complaint was not resolved at the time the complaint was voiced. She stated the complaint from #R6 was received by the staff on the night shift and they were not able to address all the patient's concerns. S30RN PI Coordinator verified the patient's concerns required investigation and follow up. S30RN PI Coordinator reviewed the complaint for patient #R5 and stated the CNA was reassigned, but she did not address the patient's concerns with the CNA until after the patient was discharged. S30RN PI Coordinator
verified the patient's complaint was not resolved at the time of the complaint and it required investigation and follow up. S30RN PI Coordinator verified she did not understand the difference between a complaint and a grievance.


Review of the 4 complaints at the off-site campus of the hospital listed from January 2013 to the present (November 6, 2013) revealed they were related to Service and Attitude of the staff.

R#1 complaint was related to not getting her pain medication in a timely matter the previous night.

R#2's complaint was related to a nurse being rude to him the previous night.

R#3's complaint was related to a nurse being rude to her the previous night.

R#4's complaint was related to the nurses not responding to the call bells timely, blood sugars not being checked, and bed baths not given.

An interview was conducted with S1DON on 11/6/13 at 2:15 p.m. She reported she realized now that she had a misunderstanding of the meaning of a grievance and a complaint. She went on to report she thought if she resolved the issue before the patient was discharged from the hospital and the patient was happy with the resolution it was a complaint and if the patient left the hospital and the patient wasn't happy with the resolution it was a grievance. S20Quality and S21DON of Hospital M were both in the room during the interview and agreed they all had a misunderstanding of the definition of a grievance and a complaint.

Based on interviews and record reviews, the hospital failed to ensure the use of restraints were in accordance with the order of a physician who was responsible for the care of a patient for 3 (#12, #17, #18) of 16 active patients reviewed.
Findings:

Review of the hospital pre-printed Physical Restraint Order Sheet revealed in part:
Reason for Restraint: If initiated without a written physician's order, the physician must be informed within 1 hour and a verbal order obtained.
This order expires 24 hours after initiated.

Patient #12
Record review revealed no verbal orders were written in Patient #12's medical record for restraints for 10/21/13 through 11/6/13. Further review revealed 13 of the 17 restraint orders written on the pre-printed order sheet did not have a verbal order from a physician or a physician's signature within 1 hour of the nurse initiating the order and 9 of 17 did not have a new order written by the physician within 24 hours.

Patient #17
Record review revealed no verbal orders were written in Patient #17's medical record for restraints for 11/02/13 through 11/05/13. Further review revealed 4 of the 4 restraint orders written on the pre-printed order sheet did not have a verbal order from a physician or a physician's signature within 1 hour of the nurse initiating the order and 2 of 3 did not have a new order written by the physician within 24 hours.

Patient #18
Record review revealed no verbal orders were written in Patient #18's medical record for restraints for 10/13/13 through 10/27/13. Further review revealed 14 of the 15 restraint orders written on the pre-printed order sheet did not have a verbal order from a physician or a physician's signature within 1 hour of the nurse initiating the order and 6 of 15 did not have a new order written by the physician within 24 hours.

In an interview on 11/6/13 at 10:56 a.m. with S25RN Charge Nurse, she said the nurses would sign the pre-printed order for the restraints and place it in the medical record every 24 hours, usually at 6:00 a.m., but the physician may not sign them until they did rounds at the hospital which may not be within 24 hours. S25RN Charge Nurse verified no documentation could be provided that when the nurse initiated the restraint orders in the morning there was a verbal or telephone order from the physician. S25RN Charge Nurse said according to the pre-printed order sheet for restraints, the order had to be rewritten by the physician every 24 hours because it expired. S25RN Charge Nurse also said the order required if the restraint order was initiated without a physician's written order, the physician had to be notified and a verbal order written within an hour. S25RN Charge Nurse verified the above mentioned Physical Restraint Orders for Patient #12 and Patient #18 had not all been reordered within 24 hours and a verbal order from a physician had not been written for all of the orders within one hour of the nurse initiating the order. S25RN Charge Nurse said she believed the Policy and Procedure for restraints required the order for restraints to be rewritten every 24 hours.

In an interview on 11/6/13 at 1:20 p.m. with S1DON, she said the hospital Policy for restraints referred to Appendix A, but did not give a time frame for renewal of restraint orders. S1DON said the pre-printed restraint order the hospital used for restraints said it expired every 24 hours. S1DON said the order also stated if initiated without a written physician's order, the physician must be informed within 1 hour and a verbal order obtained.


17091

Based on interview and record review, the hospital failed to ensure Policies and Procedures for restraints included the time frame for renewal of physician's orders to ensure the physical safety of non-violent or non-self-destructive patients.

Findings:
Review of the hospital Policy titled Restraints, with no policy number or approval date listed, revealed no documentation of time frames for renewal of Physician's Orders for restraints on a non-violent or non-self-destructive patients.

In an interview on 11/6/13 at 1:20 p.m. with S1DON, she said the hospital Policy for restraint reorders said to refer to "Appendix A", but did not give a time frame for renewal of restraint orders. S1DON said the pre-printed physician's order for the use of restraints listed that the order had to be renewed every 24 hours. S1DON also said the pre-printed physician's order listed that if it was initiated without a written physician's order, the physician must be informed within 1 hour and a verbal order obtained. S1DON said the policy should have clearly identified how soon a restraint order had to be rewritten by the physician.

Based on review of QAPI (Quality Assessment Performance Improvement) records and staff interview, the hospital failed to ensure the QAPI program was an ongoing program that showed measurable improvement in indicators as evidenced by failing to analyze the data collected to improve performance and processes of care and identify opportunities for improvement. Findings:

Review of the "Organizational Performance Improvement Plan 2013" revealed in part the following: The Performance Improvement Plan provides the framework for [Hospital] to systematically design, measure, assess, and improve processes, structures, and outcomes by utilizing the principles of continuous quality improvement (CQI)....The Quality Improvement Council has been empowered by the Governing Board to develop and oversee the organization-wide performance improvement program....All process improvement activities carried out within the organization should be performed as described in this plan, and as appropriate should be performed in an interdisciplinary team setting utilizing the following elements: 1) Process design; 2) data collection and measurement; 3) data aggregation, analysis and assessment; and 4) process improvement....Information from data assessment and analysis will be used to make changes that achieve and sustain performance improvement, enhance patient safety and reduce risk of adverse outcomes....Changes made to improve processes or outcomes will be evaluated to ensure that they achieve expected results....

Review of the Quality Council meeting minutes for the third quarter of 2013 revealed the following documentation:
PIRC (Performance Improvement Report Card) and RM (Risk Management) Review - Third Quarter 2013 revealed statistical data was collected for Respiratory Management, Management of Skin Integrity, Infection Control, Medication Management, Risk Management, Restraints, Surgical/Invasive Procedures, Blood/Blood Products, Patient Satisfaction, Information Management, and Employee Health.
This document revealed the only performance improvement actions identified in the report were as follows:
Medication Management - All medication orders are addressed by Pharmacy and followed up by DON (Director of Nursing). Responsible nurses are counseled/remediation assigned.
Restraints - Responsible staff is counseled by DON, compliance is reinforced at monthly unit staff meetings.
Surgical/Invasive Procedures - Education provided at staff meetings and individually as needed by DON.
Blood/Blood Products - Education provided at staff meetings and individually as needed to DON.
Patient Satisfaction: Areas of concern: MD (Medical Doctor) courtesy/respect, call light response time, lack of bathroom/room cleanliness, lack of quietness at night, not asked about help needed past discharge, delay in management of pain, would not recommend this hospital - Areas of concern are forwarded to the DON (cc: CEO) to present to staff at monthly unit meetings.
Information Management - HIM Director working with transcription company and corporate to resolve issues with transcription.

There was no documented evidence in the hospital's QAPI records provided for review of any corrective action plans to address the data collected. Education or counseling of the staff was the only documented improvement action.

In an interview on 11/06/13 at 4:20 p.m., S20Quality stated the data collected was reported to the Quality Council and the MEC (Medical Executive Committee). S20Quality stated they devise education on the data reported. When asked how she evaluated if the education was effective, S20Quality stated the staff have to take a test. S20Quality stated the data is discussed with the DON and nursing does the education. S20Quality stated they look at it in the next quarter. S20Quality stated if the numbers don't improve they continue to educate the staff. When asked how the hospital was using the data collected to improve performance, she stated education at staff meetings. S20Quality was unable to explain how the data collected was used to improved patient care or processes of care.

Based on record review and interview the hospital failed to focus activities on high risk, high volume or problem prone areas as evidenced by failing to develop and implement quality indicators to track, analyze, and trend the high incidents of PICC( Peripherally Inserted Central Catheter) lines dislodged and no longer secured in the patient for 14 out of 58 incidents reviewed in the last 10 months at the hospital's main campus.
Findings:

Review of the Patient Incident/Injury Log revealed out of 58 incidences on the log on the hospital's main campus from 1/13 to 10/13, 14 of the incidences were listed as the PICC (Peripherally Inserted Central Catheter) lines were "found out" of the patient.

An interview was conducted with S20Quality on 11/6/13 at 5:15 p.m. She reported that she used occurrences and incidents to choose her quality improvement indicators and she did notice the high frequency of dislodged PICC lines in the hospital. She further reported she didn't choose the dislodged PICC lines as an indicator because she figured it was just the patient population at the hospital. S20Quality reported the population is older and they seem to dislodge PICC lines frequently.

Based on interviews and record reviews, the hospital failed to accurately collect medication error data to analyze for quality assessment and performance improvement for 1 (offsite) of 2 (main, offsite) campuses reviewed for medication errors.

Findings:

Review of the 2013 Performance Improvement Plan for Evaluation and Improvement of the Medication Management System revealed in part:
II. Responsibility
The pharmacy staff through its Clinical Pharmacist and Director of Pharmaceutical Services shall assist the Pharmacy and Therapeutics committee in developing indicators, collecting data, evaluating data, assuring effectiveness, communicating relevant information, and taking actions as required.
B. Data Collection
The Pharmacist and pharmacy personnel shall be responsible for data-collection activities. The collection of data will be routinely and systematically performed from data sources pertinent to important aspects of medication use.

Review of medication error logs presented by S20Quality dated January 2013 through September 2013 revealed the following:
Main Campus- 23 patients listed with 118 medication errors.
Offsite Campus- 6 patients listed with 6 errors.

In an interview on 11/5/13 at 10:00 a.m. with S23DirPharmacy, he said at the offsite campus the pharmacy was contracted with Hospital "B". S23DirPharmacy said the offsite campus depended mostly on self-reporting by the nurses for reporting of medication errors. S23DirPharmacy said the pharmacy was supposed to report errors to S1DON or the nursing supervisor, but he was not sure if they did. S23DirPharmacy also said he did not obtain information about medication errors for QA (Quality Assessment) purposes from the pharmacy at the offsite campus. S23DirPharmacy said the pharmacy was not collecting the same error information at the offsite campus as the main campus. S23DirPharmacy also said he did not feel the error rate at the offsite campus was an accurate representation of the true number of errors the hospital encountered.

In an interview on 11/5/13 at 2:50 p.m. with S1DON, she said the reporting of medication errors and incident reports filed for medication errors was not accurate at the offsite campus. S1DON said the pharmacist at the offsite campus was not able to enter medication errors in the incident reporting system because it was online and they did not have access to the online system. S1DON said the pharmacy at the offsite campus did not provide her with a written report of errors. S1DON also verified the same methods of collection of medication errors were not used between the main campus and the offsite campus which gave an inaccurate account of medication errors. S1DON verified medication errors could not be tracked and trended for quality purposes if they were unknown.

In an interview on 11/5/13 at 3:00 p.m. with S20Quality, she stated she was the Quality Analyst Coordinator for the hospital. S20Quality stated she was aware the collection of medication errors from the offsite campus was not accurate. S20Quality said the only real reporting of medication errors from the offsite campus was self-reporting from the nurses. S20Quality said the pharmacy at the offsite campus was contracted and they did not report medication errors on incident reports or to the hospital QA program. S20Quality said the methods of medication error reporting at the offsite campus were not as inclusive as the main campus. S20Quality said the hospital was aware the error reporting was not accurate, but nothing has been done to correct the problem as of yet.

In an interview on 11/6/13 at 1:00 p.m. with S24Pharmacist, she said she was the Clinical Coordinator of the pharmacy at Hospital "B". S24Pharmacist said the pharmacy at Hospital "B" was contracted to provide medications for the offsite location. S24Pharmacist said if a medication error at the offsite campus was discovered by the pharmacy, the information was not collected for QA purposes. S24Pharmacist said if an order was written incorrectly, the order would be clarified, but not documented as a near miss or error. S24Pharmacist also said if extra medications were found in a patient's medication drawer, the medications were credited back to the patient, but the reason for the extra dose was not investigated. S24Pharmacist said she did not have access to the incident reporting computer system for the main hospital. S24Pharmacist said the pharmacy at Hospital "B" collected no data for medication errors or near misses at the offsite campus. S24Pharmacist also said she did not verbally notify S1DON or S23DirPharmacy about medication errors at the offsite campus. S24Pharmacist said the pharmacy at Hospital "B" was only contracted to provide medications to the offsite campus, not to provide any other duties.

Based on interview and record review the hospital's QAPI (Quality Assessment and Performance Improvement) Program failed to conduct P.I. (performance improvement) projects as part of their QAPI program. This failed practice was evidenced by no documented P.I. projects in their QAPI program.

Findings:

Review of the "Organizational Performance Improvement Plan 2013" revealed no documented evidence of any provisions or procedures related to Performance Improvement projects.

Review of the QAPI program, provided by S20Quality as the most current, revealed no evidence of any P.I. projects conducted by the hospital's QAPI program.

In an interview on 11/06/13 at 4:15 p.m. with S20Quality she indicated that she was the Quality Coordinator for the hospital. S20Quality further indicated that she was not conducting any P.I. projects and indicated that she mostly maintained statistical reports on ongoing occurrences and incidents within the hospital.


17091

Based on review of QAPI records, Governing Body Minutes, Service Contracts, and staff interview, the hospital's Governing Body failed to ensure the QAPI program included all hospital departments and services as evidenced by failing to include contracted services in the QAPI program. Findings:

Review of the "Organizational Performance Improvement Plan 2013" revealed in part the following: The Performance Improvement Plan provides the framework for [Hospital] to systematically design, measure, assess, and improve processes, structures, and outcomes by utilizing the principles of continuous quality improvement (CQI)....The Quality Improvement Council has been empowered by the Governing Board to develop and oversee the organization-wide performance improvement program....The Performance Improvement Program is continuous and involves the entire facility, encompassing all areas(including contracted services), directly or indirectly related to the delivery of patient care including, but not limited to Laboratory, Radiology, Medical Staff Services....The following hospital support services (including contracted services) shall analyze their scope of service and goals and recommend to the Quality Improvement Council specific quality control and performance improvement measures for inclusion in the organization-wide performance improvement program....Food and Nutrition Services, Environmental Services, Laboratory, Radiology, Cardiopulmonary Services, Medical Staff Services...

Review of the hospital's contract with Hospital "A" revealed the hospital had contracted with Hospital "A" to provide the hospital with Janitorial and Housekeeping Services, Disposal of Medical and Biohazardous Waste, Laboratory and Blood Bank Services, Radiology and Diagnostic Imaging Services, Dietary Services, Linen and Laundry Services, and Code Coverage and Emergency Services.

Review of the hospital's contract with Hospital "B" revealed the hospital had contracted with Hospital "B" to provide the hospital with Housekeeping Services, Disposal of Medical and Biohazardous Waste, Laboratory Services, Radiology Services, Nuclear Medicine Services, Dietary Services, Linen and Laundry Services, and Medical and other Supplies.

Review of the hospital's Quality Council meeting minutes and reports for 2013 revealed there was no documented evidence that Housekeeping, Laboratory, Radiology, and Dietary were included in the QAPI program.

Review of the Governing Body minutes dated 03/13/13 and 07/30/13 revealed no documented evidence that the Governing Body had identified that all hospital services (including contracted services) were not included in the QAPI program.

In an interview on 11/06/13 at 4:20 p.m. S20Quality verified she was responsible for the hospital's Quality Improvement program. S20Quality verified Housekeeping, Laboratory, Radiology, and Dietary were not included in the QAPI program.

Based on record review and interview the hospital failed to ensure the registered nurse supervised and evaluated the nursing care of each patient.
1) The RN failed to ensure wounds were assessed on admission to the hospital for 2 ( Patient #4, #14) of 13 ( Patient #2, #3, #4, #7, #10, #11, #12, #13, #14, #15, #16, #19, #20) sampled patients with wounds out of a total sample of 20;
2) The RN delegated the initial admission assessments to the LPN (Licensed Practical Nurse) for 3 (#15, #16, #18) of 10 sampled patients reviewed for initial assessments at the off-site campus (#11-#20), out of a total sample of 20.

Findings:

1) Failing to ensure wounds were assessed on admission to the hospital:

Review of the policy and procedure for Assessment, Wound and Skin Risk, revealed in part, "...Skin integrity, risk and wound assessment will be performed upon patient admission to the facility...1. Patients will have a skin assessments during the admission assessment: a. By the registered nurse as soon as possible upon patient arrival on the unit and will be completed within twelve (12 hours)...2. Skin assessment includes:
a. Viewing/inspecting bare skin...patient must be undressed in bed
b. Inspection from head to toe
c. Emphasis of inspection is over bony prominence
d. Documentation of skin disruption is recorded on the admission assessment...
Wound Assessment by admit registered nurse includes:
a. Removal of dressing and viewing wound unless contraindicated
b. Documentation of wound location and description of wound..."

Review of the hospital's policy and procedure for Assessment/Reassessment, Interdisciplinary revealed in part, "... d. When the patient has wound care needs present on admission, the wound care team will be notified for initial assessment and plan of care. Initial assessment will include site assessment, completion of Braden Scale, and collaboration with the attending physician on the wound care treatment plan..."

Review of the hospital's policy and procedure for Wound Dressing Change/Application revealed in part, "...Wounds are documented in the Medical Record stating size, appearance, and presence or absence of drainage..."

Patient #4

Review of Medical Record for Patient #4 revealed he was a 74 year old male admitted on 11/1/13 with a diagnosis of Fournier's Gangrene with intra-abdominal abscess.

Review of the Interdisciplinary Admission Assessment dated 11/1/13 revealed documentation of the Patient #4 having three (3) wounds, #1-Left Scrotum, #2- Left groin, #3- Left thigh and penis. There was no documentation of the description of the wounds stating size, appearance or presence/absence of drainage.

Review of the 24 hour Care Record dated 11/1/13 and timed 7 p.m. to 7 a.m. revealed Wound #1 was located on the left scrotum and left groin and packed with gauze,the type was an abscess and Wound #2 was on the left thigh. There was no assessment of the wounds that indicated the size, drainage, or appearances of the wounds.

Review of the 24 hour Care Record dated 11/2/13 for the 7 a.m. to 7 p.m. shift, timed 8 a.m., revealed Wound #1 was on the left scrotum/thigh. There was no assessment of the wounds.

Review of the 24 hour Care Record dated 11/2/13 for the 7 p.m. to 7 a.m. shift revealed the dressing was not removed on Wound #1(scrotum and left thigh), the type of wound was listed as abscess with s/p (status post) I and D (incision and drain).

Review of the 24 hour Care Record dated 11/3/13 for the 7 a.m. to 7 p.m. shift revealed Wound #1 was on the Left scrotum and thigh. There was no documentation of an assessment of the wound or a dressing.

Review of the 24 hour Care Record dated 11/3/13 revealed Wound #1 was on the left thigh/scrotum, the type of the wound was an abscess and there was no drainage and the dressing was dry and intact.

An interview was conducted on 11/4/13 at 2 p.m. with S1DON (Director of Nurses). She reported the nurses should have described the wound related to the size, drainage and appearance of the wound. She further reported the patient was admitted on a Friday (11/1/13) and the wound care consultant would see the patient today (11/4/13) and evaluate him.

Patient #14

Patient #14 was admitted to the hospital at the offsite campus on 11/1/13. He was a 55 year old male with a history of Diabetes Mellitus type 2, Left Foot Diabetic Foot Ulcer and Osteomyelitis.

Review of his Interdisciplinary Admission Assessment dated 11/1/13 and timed at 1910 (7:10 p.m.) revealed wound #1 was on his left foot and wound #2 was on his buttocks. There was no assessment of the wounds. Review of the physician admission orders revealed an order not to remove the dressing on the left foot wound.

Review of the 24 hour Care Record dated 11/2/13 from 7 a.m. to 7 p.m. and 7 p.m. to 7 a.m. revealed no assessment of the wound on his buttocks, only that the dressing was dry and intact.

Review of the 24 hour Care Record dated 11/3/13 for 7 a.m. to 7 p.m. revealed wound #2 was on his buttocks and the dressing was dry and intact. On the 7 p.m. to 7 a.m. shift Wound #2 was assessed as a ST (skin tear).

An interview was conducted with S12RN on 11/6/13 at 1:05 p.m. She reported she was the wound care nurse taking care of Patient #14. She reported she did a full body assessment on the patient on Monday 11/4/13 and the patient did not have a wound on his buttocks. She went on to report since the patient was admitted on Friday 11/1/13 and wound care doesn't work the weekend, her assessment was done on Monday, 11/4/13. She further reported she wasn't sure what the nurses were seeing on his buttocks, maybe it healed prior to her assessing the patient, but the nurses should have described the wound's appearance.


17091

2) The RN delegated the initial admission assessments to the LPN :

Review of the hospital policy titled, Assessment/Re-assessment, Interdisciplinary, number IX.B.5.0, approved date 02/08/12, provided as current policy, revealed in part the following: Policy: 1. Patients receiving inpatient services will have an initial assessment and appropriate follow-up assessments based upon their individual needs including physical, psychological, and social/cultural status.... 1. General 5. Initial nursing assessment of patients will be performed by a Registered Nurse. Further assessment and reassessment will be based on a collaborative effort among all health care providers.

Patient #15
Review of the patient's medical record revealed the patient was a 56 year old male admitted to the hospital on 10/17/13 with a diagnoses of Sacral Ulcer and Sepsis. Review of the "Interdisciplinary Admission Assessment (IAA) - Nursing" dated/timed 10/17/13 at 2:45 p.m. revealed the initial assessment including wound measurements was documented by S22LPN. The form also revealed the initial assessment was co-signed by S14RN Charge.

In an interview on 11/06/13 at 11:05 a.m., S14RN Charge reviewed the initial assessment for Patient #15 and verified S22LPN had done the initial assessment and had measured the patient's wound. S14RN Charge stated she goes in to the patient's room and "looks at the skin", but does no other assessment. S14RN Charge stated she does not ask the patient any questions and does not have to write anything on the initial assessment.

Patient #16
Review of the patient's medical record revealed the patient was a 66 year old male admitted to the hospital on 11/04/13 with a diagnosis of sacral and buttock wounds. Review of the "Interdisciplinary Admission Assessment (IAA) - Nursing" dated/timed 11/04/13 at 6:25 p.m. revealed the initial assessment including wound measurements was documented by S15LPN. The form also revealed the initial assessment was co-signed by S16RN.

In an interview on 11/06/13 at 10:45 a.m., S14RNCharge reviewed the initial assessment for Patient #16 and indicated that S15LPN had done the initial assessment and had measured the patient's wound. S14RNCharge indicated that it is not uncommon for LPN's do the initial assessments on patients. S14RNCharge indicated that the co-signature by S16RN on the first page of the assessment sheet on Patient #16 was in reference to the patient's personal inventory upon admit and not the assessment itself.

Patient #18
Review of the medical record for Patient #18 revealed she was a 57 year old admitted on 10/22/13 for diagnosis which included pressure ulcers. Review of the Interdisciplinary Admission Assessment-Nursing dated 10/22/13 at 5:55 p.m. revealed the assessment was signed by S29LPN. Further review revealed no Registered Nurse had cosigned the assessment.

In an interview on 11/6/13 at 11:24 a.m. with S25RN Charge Nurse, she stated S29LPN completed the Interdisciplinary Admission Assessment-Nursing for Patient #18. S25RN Charge Nurse verified no Registered Nurse had cosigned with the assessment or documented an initial assessment.


30172




30364

Based on record review and interviews the hospital failed to ensure nursing care of each patient was assigned by the registered nurse to nursing staff who were determined to be competent as evidenced by failure to ensure registered nurses assigned to patients with a Propofol intravenous drip were deemed competent.
Findings:

Review of the Louisiana State Board of Nursing, "Declaratory Statement on the Role and Scope of Practice of the Registered Nurse in the Administration of Medication and Monitoring of Patients During the Levels of Procedural Sedation (Minimal, Moderate, Deep, and Anesthesia) as Defined Herein" revealed in part the following: Position Statement, March 17, 2004.....The Registered nurse (non-CRNA) (Certified Registered Nurse Anesthetist) shall have documented education and competency to include: A. Knowledge of sedative drugs and reversal agents, their dosing and physiologic effects. Advanced Cardiac Life Support....Skill in establishing an open airway, head-tilt, chin lift, use of bag-valve-mask device, oral and nasal airways, and emergency procedures. This includes rescuing a patient that may progress beyond deep sedation. Demonstration of the acquired knowledge of anatomy, physiology, pharmacology, and basic cardiac arrhythmia recognition;, recognize complications of undesired outcomes related to sedation/analgesia; demonstrated appropriate interventions in compliance with standards of practice, emergency protocols, or guidelines....
B. Competencies will be measured initially during orientation and on an annual basis....

Review of the hospital's policy for IV (intravenous) Drugs Requiring Monitoring Upon Administration revealed in part, "...Intravenous medications that require a level of care of continuous monitoring or titration within prescribed monitoring parameters to attain or maintain hemodynamic stability shall be prescribed by a physician and administered by qualified staff in an appropriate setting..."

Review of Patient # 8's medical record revealed he was placed on a Propofol intravenous drip on 9/24/13.

Review of Patient #12's medical record revealed she was placed on a Propofol intravenous drip on 10/12/13.

Review of the medical record for Patient #8 revealed S17RN and S19RN were assigned to take care of Patient #8 on the day he was administered a Propofol intravenous drip.

Review of S17RN's and S19RN's training records revealed no documentation of their competency related to administrating and monitoring a patient on a Propofol drip.

An interview was conducted on 11/6/13 at 1 p.m. with S1DON (Director of Nursing). She reported all the registered nurses on staff can take care and be assigned to a patient on a Propofol intravenous drip. She went on to report that the hospital does not check the registered nurses' competency in administering and maintaining a patient on a Propofol intravenous drip.


17091

Based on observation and interview the hospital failed to ensure medical records were properly stored at the offsite campus as evidenced by failing to protect approximately 500 medical records from water damage.
Findings:

An observation was made on 11/6/13 at 11:00 a.m. in the offsite medical records department of approximately 500 medical records on open shelving without front or back coverings. There was no protection from water damage for the patients' medical records if a fire activated the sprinkler system in the ceiling.

An interview was conducted with S18RHIA (Registered Health Information Administrator) on 11/6/13 at 11 a.m. She confirmed the medical records were not protected from water damage with the records being stored on open shelving.

Based on interviews and record reviews the hospital failed to follow their policy on properly completing informed consents for patients having procedures. This failed practice was evidenced by 8 of 8 (#1, #3, #5, #7, #10,#11,#12, #17) patient informed consents reviewed out of a total sample of 20.

Findings:
Review of the hospital policy, titled "Informed Consent", revised on 06/2013, provided by S1DON as the most current, revealed in part: The practitioner performing the procedure is responsible for obtaining the patient's informed consent prior to the treatment or procedure. The person performing the procedure must disclose to the patient the potential benefits, the potential problems, the possible results of non-treatment and the alternatives so the patient can make an informed decision on whether or not to undergo the procedure or treatment. It is the responsibility of the licensed nurse involved in the patient's care to witness the signature of the practitioner and the patient or the responsible individual giving consent. When verbal/telephone consent is necessary, two (2) witnesses shall be required for telephone consent, one of which is the person performing the procedure and the other person should be a licensed personnel.

Review of the "Informed Consent Special Procedure- PICC/Midline" consent form revealed three (3) boxes to be checked by the practitioner obtaining the consent. The first box indicates that the patient understands that local analgesic medication will be used for the procedure. The second box indicates that the alternatives to the procedure and the probability of success have been fully explained to the patient, and includes a blank space for the practitioner to write the alternatives or to check that no other alternatives are available. The third box indicates the refusal of the procedure by the patient.

Patient #1
Review of the "Informed Consent Special Procedure- PICC/Midline" consent form dated 11/01/13 revealed that box one and box two were not checked and indicated that no alternatives to the procedure were discussed with the patient nor were there any alternatives written in by the practitioner performing the procedure.

Patient #3
Review of the "Informed Consent Special Procedure- PICC/Midline" consent form dated 10/17/13 revealed that box one and box two were not checked and indicated that no alternatives to the procedure were discussed with the patient nor were there any alternatives written in by the practitioner performing the procedure.

Patient #5
Review of the "Informed Consent Special Procedure- PICC/Midline" consent form dated 10/31/13 revealed that box one and box two were not checked and indicated that no alternatives to the procedure were discussed with the patient nor were there any alternatives written in by the practitioner performing the procedure.

Patient #7
Review of the "Informed Consent Special Procedure- PICC/Midline" consent form revealed that the consent was not dated by either the patient or the practitioner performing the procedure. Box two was not checked and indicated that no alternatives to the procedure were discussed with the patient nor were there any alternatives written in by the practitioner performing the procedure.

In an interview on 11/05/13 at 12:45 p.m with S2RNCharge she was asked about the informed consent for Patient #7. S2RNCharge indicated that the procedure was performed on 11/02/13 by S13RN, the PICC nurse around 11:00 a.m. that day. S2RNCharge indicated the LPN who worked the night shift (6pm-6am) obtained the informed consent for the procedure and further indicated that the night nurses usually obtained the informed consents from patients who are having procedures in the morning.

Patient #10
Review of the "Informed Consent Special Procedure- PICC/Midline" consent form dated 10/25/13 revealed that box one and box two were not checked and indicated that no alternatives to the procedure were discussed with the patient nor were there any alternatives written in by the practitioner performing the procedure.

Patient #11
Review of the "Informed Consent Special Procedure- PICC/Midline" consent form dated 10/31/13 revealed that box one and box two were not checked and indicated that no alternatives to the procedure were discussed with the patient nor were there any alternatives written in by the practitioner performing the procedure.

Patient #12
Review of the "Consent for Wound Debridement" dated 10/30/13 revealed that the consent was complete except for the signature of the patient's responsible person's name which was printed on the form above the signature line.

Patient #17
Review of the "Informed Consent Special Procedure- PICC/Midline" consent form dated 11/04/13 revealed that box one and box two were not checked and indicated that no alternatives to the procedure were discussed with the patient nor were there any alternatives written in by the practitioner performing the procedure. The informed consent further indicated it was a telephone consent and was witnessed by 2 licensed nurses and neither of them was the practitioner performing the procedure.

In a telephone interview on 11/06/13 at 10:15 a.m. with S13RN, PICC nurse he indicated he was the practitioner certified to insert PICC (Peripherally Inserted Central Catheter) lines. S13RN, PICC nurse indicated that he was responsible for explaining the procedure to the patients. S13RN, PICC nurse indicated that the nurses on the night shift will often obtain the consent for the PICC line placement from the patient. S13RN, PICC nurse was asked about the boxes on the informed consent form. He indicated that he explains the procedure and the alternatives to the patient and does not check the boxes and indicated that he should check the boxes.

In an interview on 11/06/13 at 4:00 p.m. with S1DON she indicated that all informed consents should be completed according to hospital policy. S1DON further indicated that all informed consents should be obtained by the practitioner performing the procedure and indicated that nurses were only to witness the patient signature after the practitioner explained the procedure to the patient and signed the consent. S1DON indicated that telephone consents should be witnessed by two (2) licensed staff, one of which was the person performing the procedure.

Based on interview and record review, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with acceptable standards of practice for 1 (#5) of 5 (#1, #3, #5, #7, #9) patients reviewed at the hospital for overridden medication removal on 11/2/13 and 11/3/13. This deficient practice is evidenced by failing to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist before the first dose was dispensed for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications.

Findings:

Review of the hospital Policy titled First Dose Medications, Policy Number 1730, Reviewed 5/11 revealed in part:
Policy: Any medication administered for the first time during a hospitalization without documentation indicating the patient has previously received the medication is considered a first dose medication.

Review of the hospital Policy titled Review of the Medication Orders for Appropriateness, Policy Number VI.B.16.0, Revised 6/2012 revealed in part:
1. Prior to obtaining any medications from floor stock or an automated dispensing machine, a pharmacist reviews all prescription or medication orders, with the following exceptions:
1.1 A licensed Independent Practitioner (LIP) controls the ordering, preparation, and administration of the medication. In this facility this is applicable in the following areas/circumstances:
1.1.1. Urgent situations where the resulting delay would harm the patient
1.1.2 Departments with direct LIP control of the ordering, preparation, and administration of the medication.
4. Prior to the pharmacist dispensing the first dose of medication he/she is to review all prescriptions and the minimum patient specific information for the following:
-Appropriateness of the drug, dose, frequency, and route of administration
-Therapeutic duplication
- Real or potential allergies or sensitivities
- Real or potential interactions between the prescription and other medications, food and laboratory values
- Other contraindications
- Variation from organizational indication/criteria for use
-Other relevant medication-related issues or concerns
- Concerns, issues or questions that need to be clarified with the individual prescriber.

Review of the pharmacy medication dispensing system overrides revealed the following medications was removed after pharmacy hours of operation for Patient #5:
Lactulose 20 gm/30 ml sol removed on 11/3/13 at 8:49 a.m.
Levofloxacin/D5W 500mg IPS on 11/2/13 at 8:23 p.m.

Review of the MAR for Patient #5 dated 11/3/13 revealed Lactulose 30 mg PO BID was documented as having been given at 9:00 a.m.

Review of the MAR for Patient #5 dated 11/2/13 revealed Levaquin (Levofloxacin) 500mg was documented as having been administered at 9:00 p.m.

In an interview on 11/5/13 at 10:00 a.m. with S23DirPharmacy, he said the pharmacy hours of operation were 8:00 a.m. until 4:30 p.m. Monday through Friday. S23DirPharmacy said on weekends and holidays, the pharmacist came in the morning and filled prescriptions and then someone was on call if needed. S23DirPharmacy said when a medication was ordered, the order was placed into a box at the nurse's station, and then it was picked up by the technician or himself. At night, S23DirPharmacy said if the first dose of a medication was ordered the nurses could override the automated medication dispensing system to obtain the medication. S23DirPharmacy said a pharmacist would not review the medications until the next day, which would be after the first dose had been given. S23DirPharmacy said a pharmacist reviewed all first dose medications at the offsite campus. S23DirPharmacy also said the medications for Patient #5 listed above were first dose medications that were not reviewed by a pharmacist before the first dose was dispensed and administered.

Based on interviews and record reviews, the hospital failed to collect accurate medication error data for reporting to patient's physicians and to the hospital's quality assessment and performance improvement program as evidenced by the offsite campus' contracted pharmacy not collecting and reporting any medication error data to the hospital.

Findings:

Review of the Hospital Policy titled Medication Administration Errors, Policy Number 1206, Revised 6/12, revealed in part:
Medication errors need not necessarily have caused harm to the patient. Written reports shall also be made of minor errors that result in no harm to the patient but have a potential adverse effect on patient care.
Reports:
The person who discovers the error (or the person designated by the individual in charge) shall prepare an occurrence report on the hospitals approved form.

Review of medication error logs presented by S20Quality dated January 2013 through September 2013 revealed the following:
Main Campus- 23 patients listed with 118 medication errors.
Offsite Campus- 6 patients listed with 6 errors.

In an interview on 11/5/13 at 10:00 a.m. with S23DirPharmacy, he said at the offsite campus the pharmacy was contracted with Hospital "B". S23DirPharmacy said the offsite campus depended mostly on self-reporting by the nurses for reporting of medication errors. S23DirPharmacy said the pharmacy was supposed to report errors to S1DON or the nursing supervisor, but he was not sure if they did. S23DirPharmacy also said he did not obtain information about medication errors for QA (Quality Assurance) purposes from the pharmacy at the offsite campus. S23DirPharmacy said the pharmacy was not collecting the same error information at the offsite campus as the main campus. S23DirPharmacy also said he did not feel the error rate reported at the offsite campus was an accurate representation of the true number of errors the hospital encountered.

In an interview on 11/5/13 at 2:50 p.m. with S1DON, she said the reporting of medication errors and incident reports filed for medication errors was not accurate at the offsite campus. S1DON said the pharmacist at the offsite campus was not able to enter medication errors in the incident reporting system because it was online and they did not have access to the online system. S1DON said the pharmacy at the offsite campus did not provide her with a written report of errors. S1DON also verified the same methods of collection of medication errors were not used between the main campus and the offsite campus which gave an inaccurate account of medication errors. S1DON verified medication errors could not be tracked and trended for quality purposes or reported to physicians if they were unknown.

In an interview on 11/5/13 at 3:00 p.m. with S20Quality, she stated she was the Quality Analyst Coordinator for the hospital. S20Quality stated she was aware the collection of medication errors from the offsite campus was not accurate. S20Quality said the only real reporting of medication errors from the offsite campus was self-reporting from the nurses. S20Quality said the pharmacy at the offsite campus was contracted and they did not report medication errors on incident reports or to the hospital QA program. S20Quality said the methods of medication error reporting at the offsite campus were not as inclusive as the main campus. S20Quality said the hospital was aware the error reporting was not accurate, but nothing has been done to correct the problem as of yet.

In an interview on 11/6/13 at 1:00 p.m. with S24Pharmacist, she said she was the Clinical Coordinator of the pharmacy at Hospital "B". S24Pharmacist said the pharmacy at Hospital "B" was contracted to provide medications for the offsite location. S24Pharmacist said if a medication error at the offsite campus was discovered by the pharmacy, the information was not collected for QA purposes. S24Pharmacist said if an order was written incorrectly, the order would be clarified, but not documented as a near miss or error. S24Pharmacist also said if extra medications were found in a patient's medication drawer, the medications were credited back to the patient, but the reason for the extra dose was not investigated. S24Pharmacist said she did not have access to the incident reporting computer system for the main hospital. S24Pharmacist said the pharmacy at Hospital "B" collected no data for medication errors or near misses at the offsite campus. S24Pharmacist also said she did not verbally notify S1DON, S23DirPharmacy or physicians about medication errors at the offsite campus. S24Pharmacist said the pharmacy at Hospital "B" was only contracted to provide medications to the offsite campus, not to provide any other duties.

Based on observation and interview, the hospital failed to ensure all equipment was maintained in a manner to ensure an acceptable level of safety and/or quality as evidenced by failing to ensure the functionality of a nurse call button located on the handrails of the beds on all patient beds at both the main campus and the offsite campus.

Findings:

Observations were made on Hall "B" of the main campus of the hospital on 11/04/13 between 10:40 a.m. and 11:00 a.m. with S28RN. A nurse call button was noted to be on the handrail of the beds in rooms 361, 362, 363, 364, 365, 366, 367, and 370. The beds were observed to be two different types of beds with both types having a nurse call button in the side rails of the beds. The button was noted to be non- functional as it failed to activate any type of nurse call system. S28RN confirmed that the nurse call button located on the handrails of the patient beds was not functioning when pressed. S28RN stated, "They all have call lights in the bed rails and none work". S28 RN indicated that they have a nurse call system which included a cord with a button and reported that patients are instructed to use this call system. S28RN verified a patient who may be confused or sedated, or a family member not present for the room orientation could press the nurse call button on the handrail of the bed thinking they are calling for assistance without the nursing staffs' knowledge due to the call button not working.

Observations were made on Hall "A" of the main campus of the hospital on 11/04/13 between 1:30 p.m. and 2:00 p.m. with S1DON (Director of Nursing). Observations of the unoccupied rooms on Hall "A" revealed all the patient beds had nurse call buttons in the side rails of the bed and none of them were functional. S1DON stated all the patient beds were either Stryker or Hill-Rom. S1DON verified the main campus had 29 beds and all the beds had a call light button in the side rails that was not functional.

Observations were made on both hallways of the off-site campus of the hospital on 11/06/13 between 9:15 a.m. and 9:35 a.m. with S14RN Charge. A nurse call button was noted to be on the handrail of the beds in rooms 475, 476, 477, and 479. The button was noted to be non- functional as it failed to activate any type of nurse call system. S14RN Charge confirmed that the nurse call button located on the handrails of the patient beds was not functioning when pressed. S14RN Charge stated all the beds have call lights in the bed rails and none of side rail call lights were functional. S14RN Charge stated they have a nurse call system which included a cord with a button and reported that patients are instructed to use this call system. S14RN Charge verified a patient who may be confused or sedated, or a family member not present for the room orientation could press the nurse call button on the handrail of the bed thinking they are calling for assistance without the nursing staffs' knowledge due to the call button not working. S14RN Charge verified the off-site campus had 28 beds and all the beds had a call light button in the side rails that was not functional.

Based on observation, interviews and record reviews the hospital (main campus) failed to provide proper ventilation according to the manufacturer's MSDS (Material Safety Data Sheet) in a room where Cidex-OPA solution was used and the hospital failed to have a policy in place for Cidex-OPA use. This failed practice was evidenced by: 1) Cidex-OPA solution being used in an anteroom with no documented evidence that the anteroom had proper ventilation and 2) no documented evidence of a hospital policy for Cidex-OPA use.

Findings:
An observation of the anteroom was made on 11/04/13 of a counter on the back wall with a sink that contained a metal container that contained a solution in it and was labeled "Cidex-OPA". A gallon container of Cidex-OPA solution and Cidex-OPA test strip bottles were noted on the left side of the counter and a box of standard use exam gloves was also noted on the counter.

Review of the MSDS sheet, provided by S4WoundCare revealed that inhalation of Cidex-OPA vapors during use may cause asthma-like symptoms. The review revealed that personal precautions should be used when coming in contact with Cidex-OPA (chemical resistant gloves and suitable body protection). The MSDS sheet further revealed that Cidex-OPA should be used in well ventilated areas with appropriate exhaust ventilation of a minimum of 10 air exchanges per hour.

In an interview on 11/04/13 at 11:30 a.m. with S4WoundCare, she indicated that the anteroom was the decontamination room for the wound care personnel. S4WoundCare indicated that she used the room for cleaning and packaging contaminated instruments used in wound care debridement. S4WoundCare indicated she used Cidex-OPA routinely in the cleaning of the instruments. S4WoundCare indicated she wore standard exam gloves when using Cidex-OPA and did not use chemical resistant gloves. S4WoundCare further indicated she was unsure of the ventilation or air exchanges in the anteroom (decontamination room). S4WoundCare indicated she was not sure if the hospital had a policy on the use of Cidex-OPA.

In an interview on 11/04/13 at 2:00 p.m. with S1DON she indicated that the anteroom was used by the wound care team for cleaning of their instruments. S1DON indicated she was not sure of the processes used by the wound care team. S1DON further indicated the hospital did not have a policy on the use of Cidex-OPA.

In an interview on 11/05/13 at 12:15 p.m. with S9Maintenance he indicated he was not aware that the hospital (main campus) had a room used for decontamination of soiled instruments. S9Maintenance indicated he thought all soiled instruments were sent to the contracted hospital for reprocessing. S9Maintenance was shown the anteroom (decontamination room) used by the wound care team and was asked about the ventilation in that room. S9Maintenance indicated that maintenance did not do ventilation checks for air exchanges in that room since it was considered an anteroom and since maintenance was not aware it was used as a decontamination room where Cidex-OPA was used. S9Maintenance further indicated the anteroom was not a well ventilated room due to its size and he indicated that he did not know the air exchanges.

Based on observations, interviews and record reviews the hospital failed to provide a sanitary environment to avoid sources and transmission of infections and failed to monitor compliance with infection control policies, procedures, protocols and other infection control requirements as evidenced by:
1) failing to be consistent in following their contact precaution policy with patients on contact precautions receiving therapy in the therapy department (both campuses).
2) failing to have a functional workflow in the decontamination room (anteroom) for cleaning and processing soiled and contaminated instruments after patient use (main campus).
3) failing to have respiratory sterile supplies stored in a clean environment by storing them in a room with exposed A/C duct work and a cooling machine with a drip pan (main campus).
4) failing to store clean dialysis machines ready for patient use in a clean area.
5) failing to maintain a sanitary hospital environment in the clean supply rooms and clean storage rooms.
6) failing to maintain a sanitary hospital environment in patient rooms by failing to clean and disinfect patient bed rails.

Findings:

1) failing to be consistent in following their contact precaution policy with patients on contact precautions receiving therapy in the therapy department.
Review of the hospital policy, "Guidelines for Transmission Based Precautions" revised on 09/21/12, provided by S3Infection Control as the most current, revealed that patients under contact precautions should avoid being in the same room with patients who have conditions that may increase the risk of adverse outcomes from infections or that may facilitate transmission to those patient who are immunocompromised or have wounds. The policy further revealed that staff are to wear and change protective attire and perform hand hygiene for patients in the same room with a patient on contact precautions, regardless of whether the other patients are on contact precautions. The policy indicated that patients on contact precautions should have limited transport and limited movement outside of the room unless for medically-necessary purposes. The policy further indicated that when transporting patients on contact precautions staff should remove and dispose of contaminated PPE (personal protective equipment) before leaving the patient's room and perform hand hygiene prior to transporting the patient and then don clean PPE to care for the patient at the transport destination.

An observation on 11/04/13 at 10:30 a.m. in the therapy department revealed 4 patients receiving therapy in the therapy department. The therapists were observed wearing gloves and no other PPE.

In an interview on 11/04/13 at 10:40 a.m. with S5PT she indicated that one of the patients receiving therapy today was on contact wound precautions for MRSA (Methicillin Resistant Staphylococcus Aureus) and the other 3 patients had wounds and were not on contact precautions. S5PT indicated that patients on contact precautions were allowed to receive therapy in the therapy department with other patients as long as their wounds were covered. S5PT indicated that the therapy department did have the capability of performing therapy on patients on contact precautions while the patient remained in their room and that they only did that for patients who are on C.diff (Clostridium Difficile) contact precautions. S5PT indicated that when they transported patients on contact precautions from their rooms to the therapy department the therapist wear PPE (gown, gloves, shoe covers) to enter the patient's room and removed and disposed of the PPE before they left the patient's room. S5PT further indicated that when they arrived at the therapy department, the therapists only wore gloves when coming in contact with the patient and would only change gloves between other patient contacts. S5PT indicated they did not wear any other PPE in the therapy department for patients on contact precautions.

In an interview on 11/04/13 at 10:50 a.m. with S6ST and S7OT they indicated the above information from S5PT was the procedure they followed for patients on contact precautions.

An observation on 11/05/13 at 9:50 a.m. in the therapy department revealed 4 patients were receiving therapy in the therapy department. The therapists were observed wearing gloves and no other PPE. S7OT verified 2 patients in the group had wounds with MRSA and were on contact isolation.

In an interview on 11/05/13 at 1:00 p.m. with S3Infection Control she was made aware of the contact precaution procedure followed by the therapy department. S3Infection Control indicated that the hospital's Infection Control policy on contact precautions were not consistently adhered to by all staff in all departments.

2) failing to have a functional workflow in the decontamination room (anteroom) for cleaning and processing soiled and contaminated instruments after patient use.
An observation of the anteroom was made on 11/04/13. Observations noted were: 1) entrance and exit to room through the same door, 2) a counter top with a piece of red tape placed down the center dividing the countertop into 2 sides, 3) metal containers x 2 in the sink to the right of the red tape on counter containing cleaning solutions, 4) a "hopper" sink near the floor containing a chest level faucet on the right wall in the corner with no splash guard, 5) instruments packed in sterilization packs on an overhead bed table to the right of the room, 6) Cidex-OPA solution and Cidex-OPA test strip bottles to the left of the red tape on the counter, 7) instruments on a towel on the left side of red tape on the counter, 8) a cabinet under the counter with instrument cleaning solutions.

In an interview on 11/04/13 at 11:30 a.m. with S4Wound Care, she indicated the anteroom was used as the decontamination room for the cleaning and processing of the soiled and contaminated instruments used for patient's wound debridement by the wound care team. S4WoundCare indicated that the red tape on the counter divided the soiled area from the clean area when the counter was used for cleaning and processing of soiled debridement instruments. S4WoundCare indicated she would enter with soiled instruments and exit with the cleaned instruments packaged for reprocessing through the same single door in the room. She further indicated that only the counter was divided into dirty and clean, not the room. S4WoundCare indicated she would place the cleaned instruments packaged for reprocessing on the overhead bed table on the right side of the room due to limited space in the room. She further indicated that she did not use the sink on the counter because that was where she placed the containers with the enzymatic solution and the Cidex-OPA solution used for decontaminating the instruments. S4WoundCare indicated she used the "hopper" sink and faucet on the right wall in the corner for the scrubbing and the rinsing of the instruments in the decontamination process. S4WoundCare indicated that she does not turn the water on too much in the "hopper" sink because it did not have a tall enough splash guard around it. S4WoundCare was asked if she had a policy on the decontamination of instruments in the anteroom. S4Woundcare indicated she did not have a policy for decontamination specific to the use of the anteroom.

In an interview on 11/05/13 at 4:00 p.m. with S3Infection Control, she was shown the anteroom that was used as the decontamination room for the cleaning and processing of the soiled and contaminated instruments used for patient's wound debridement by the wound care team. S3Infection Control indicated she was not aware that the hospital (main campus) had a room used for decontamination of soiled instruments. S3Infection Control indicated she thought all soiled instruments from the main campus were sent to the contracted hospital for reprocessing. S3Infection Control further indicated that the anteroom was not properly set up to be a decontamination room.

3) failing to have respiratory sterile supplies stored in a clean environment by storing them in a room with exposed A/C duct work and a cooling machine with a drip pan (main campus).
An observation was made on 11/05/13 of the respiratory supply room. The respiratory supply room was located behind the locked nurse's medication room in a small room that contained the Cardiac/Monitor computer server and a Movin Cool Machine that was observed to have a dirty air filter, a water drip pan and exposed A/C duct work coming from the ceiling. On the left side of the cooling machine that had the dirty air filter were sterile respiratory supplies on an uncovered storage rack. On the right side of the cooling machine were additional respiratory sterile supplies on an uncovered storage rack where the cooling machine had to be moved in order to access the sterile supplies. The floor was noted to have dried yellowish stains and dust and there was dust on the shelving.

In an interview on 11/05/13 at 3:30 p.m. with S10RT he indicated that the room was the respiratory department's only supply room that contained both clean and sterile supplies. S10RT indicated that the cooling machine had to be "on" at all times to prevent the Cardiac/Monitor computer server from overheating. S10RT further indicated that the water drip pan under the cooling machine had to be emptied often to prevent the water from overflowing onto the floor. S10RT indicated he did not think the room was cleaned daily by housekeeping because of its location behind the locked nurse's medication room.

In an interview on 11/05/13 at 3:50 p.m. with S3Infection Control she was shown the respiratory department's supply room (where their sterile and clean supplies were stored) that was located behind the locked nurse's medication room in a small room that contained the Cardiac/Monitor computer server and a Movin Cool Machine (that was observed to have a dirty air filter, a water drip pan and exposed A/C duct work coming from the ceiling). S3Infection Control indicated she was not aware that this room was used for the respiratory supplies and confirmed the findings presented to her and indicated that the room should not be used for storage of sterile and clean supplies.

4) failing to store clean dialysis machines ready for patient use in a clean area.
Review of the policy titled Environmental Services in Association with Host Hospital, Policy Number: I.H.1.0, Approval date 5/18/11, revealed in part:
PH (The Hospital) shall be responsible for cleaning and disinfecting area-specific patient care equipment (i.e. IV pumps, feeding pumps, ventilators, etc.) utilizing host hospital ' s designated cleaning products.
e. after cleaning, the equipment is to be covered with a plastic bag, tagged with the date and initials of the individual performing the cleaning, and placed in a clean storage area of PH.
Observation on 11/4/13 at 10:38 a.m. revealed 3 dialysis machines being stored in the conference room. The 3 machines were observed having tags on them listing they were ready for use. The dates and times of the last disinfections were listed as 11/4/13 at 8:44 a.m., 9:41 a.m. and 9:35 a.m. Further review revealed the machines were not covered with a plastic bag.
In an interview on 11/4/13 at 11:13 a.m. with S2RN Charge Nurse, she said the dialysis machines were kept in the conference room because they did not have enough storage space in the unit, so there was nowhere else to keep them.

5) failing to maintain a sanitary hospital environment in the clean supply rooms and clean storage rooms.
Room 484
An observation on 11/6/13 at 8:30 a.m. revealed a clean storage room numbered 484 at the offsite campus revealed dust, dirt and hairballs on the floor, 2 open boxes of gloves on the floor, 3 open boxes of gloves underneath a printer, paper and debris under the clean linen cart, a candy wrapper on the floor, 3 pairs of gloves on the floor, 4 walkers stacked on the floor, a dirty fan stored in the room, and a mattress on the floor.
In an interview on 11/6/13 at 8:40 a.m. with S25RN Charge Nurse, she said the clean supply room was supposed to be cleaned every couple of days by housekeeping. S25RN Charge Nurse said she was not aware of any policies and procedures governing the cleaning of the supply rooms.
Clean Supply
An observation of a clean supply room was made on 11/4/13 at 11:00 a.m. at the offsite campus. Several pieces of paper were noted on the floor. Underneath the shelving units was wadded up paper, a battery, 2 empty boxes, 4 syringes, 6 paper medicine cups, 3 wrapped 18 gauge needles, 4 IV (intravenous) sets and 2 IV bags of fluid.
In an interview on 11/4/13 at 11:31 a.m. with S2RN Charge Nurse, she verified the above mentioned items were located under the shelves and on the floor in the clean storage room. She stated, "The floor was supposed to be swept and mopped daily, but housekeeping obviously had not cleaned beneath the shelves in a long time."

6) failing to maintain a sanitary hospital environment in patient rooms by failing to clean and disinfect patient bed rails.
Observations were made on both hallways of the off-site campus of the hospital on 11/06/13 between 9:15 a.m. and 9:35 a.m. with S14RN Charge Nurse. The patient bed in room 475 was observed to have a side rail with a large area of enamel missing from the bottom of the side rail on the right side of the bed, resulting in the inability to have a smooth wipeable surface for disinfection. The exposed metal was observed to have a rough surface and rust-like appearance. S14RN Charge Nurse verified the side rail had an exposed area of rust.
The patient bed in room 476 was observed to have a sticky residue on the side rails and the side rails were observed to have rusted areas where the enamel was missing.
The patient bed in room 477 was observed to have tape and rusted areas on both side rails of the bed.
The patient bed in room 479 was observed to have a sticky residue on the side rails and tape on the over bed table.
The above observations were confirmed by S14RN Charge Nurse at the time of the observation.


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