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Based on interviews and document review, the hospital failed to ensure:

a. the designated Infection Control Preventionist was qualified by education, training, experience, or certification (see Tag A-0748),

b. bronchoscopes were reprocessed according to manufacture's guidelines and nationally recognized guidelines, (see Tag A-0749), and

c. staff adhered to infection control policies and procedures for patients in isolation rooms (see Tag A-0749).

Based on interview and record review, the hospital failed to appoint a single chief executive officer who was responsible for managing the main hospital and off-site location.


This failed practice had the potential to increase confusion regarding management of the entire hospital and its off-site location.


Findings:


On 03/28/17 at 9:45 am, Staff A identified himself as Chief Executive Officer (CEO) and stated the hospital was comprised of a main campus at Muskogee (MU) and off-site location at Broken Arrow (BA), both with the same CMS certification number and State license number:


The hospital provided a 2017 organizational chart that listed Staff A as "Market CEO", and showed a vacant position for a "CEO" at the Muskogee location.


The hospital's Medical Executive Committee Meeting minutes were reviewed for 11/16/16, 10/19/16, , 5/18/16, 5/11/16, 4/20/16, and 9/9/15. These meeting minutes listed both Staff A and Staff Y as CEOs.


The hospital's Job Description for "Market CEO" and "CEO" was reviewed. The position summary within the Job Description was the same for both job titles. Both summaries described positions as being accountable for operational oversight of two or more hospital systems...and services in a manner that optimizes provision of care and outcomes for the long term care patients.

Based on record review and interview, the hospital failed to provide documentation of a written notice given to each patient reporting the grievance resolution and follow its policy in regards to responding to grievances for seven of seven grievance records (Patient #21, 22, 23, 24, 25, 26 and 27) reviewed.


Findings:


The hospital's policy titled, "Complaint and Grievance Process" showed,

~ grievance[s] should be resolved within 7 working days

~the party filing the grievance will be provided written notification of the outcome of the grievance review and investigation

~if a resolution cannot be completed within 7 working days, then an acknowledgement letter will be sent to the complainant within 7 working days of the receipt of the grievance


Documents titled, "Cornerstone Hospitals of Oklahoma, Muskogee Complaint Log 2016" and "Complaint/Grievance Form" showed the following results:

On 3/17/16, Patient #21 submitted a grievance; letter was sent on 4/15/16. A period of 22 working days after grievance filed.

On 3/21/16, Patient #22 submitted a grievance; letter was sent on 4/15/16. A period of 20 working days after grievance filed.

On 3/21/16, Patient #23 submitted a grievance; letter was sent on 4/15/16. A period of 20 working days after grievance filed.

On 5/4/16, Patient #24 submitted a grievance; letter was sent on 5/20/16. A period of 13 working days after grievance filed.

On 5/9/16, Patient #25 submitted a grievance; letter was sent on 6/30/16. A period of 39 working days after grievance filed.

Patient #26 submitted a grievance no date was shown; letter was sent on 9/12/16.

On 9/20/16, Patient #27 submitted a grievance; letter was sent on 10/18/16. A period of 23 working days after grievance filed.

On 3/30/17, an interview was conducted with Staff C who stated written notifications are not being sent to complainants according to policy.

Based on record review and interview, the hospital failed to follow its policies and procedures regarding the protection of patients from abuse and neglect, and protect patients during an investigation of alleged verbal, physical abuse, mistreatment, and/or harassment for five (Patient #21, 22, 23, 24 and 25) of seven complaints/grievances regarding staff treatment. This failed practice had the potential to affect all patients admitted to the hospital.


Findings:


A policy titled, "Abuse, Reporting Suspected Abuse" revised on 5/2016, showed no policy or process for protection of patients from abuse during an investigation.

On 3/29/17 at 2:45 PM, Staff C stated the policy titled, "Abuse, Reporting Suspected Abuse" is used for all abuse incidences.

On 3/30/17 at 9:00 AM, surveyors received another copy of the policy titled, "Abuse, Reporting Suspected Abuse" revised on 5/2016, which included the statement, " ...if abuse is alleged by a patient against a hospital employee, the patient will immediately be removed from the staff members care. The staff member will be suspended while a full investigation is undertaken ..." The original policy provided to surveyors did not contain this statement.

A policy titled, "Plan for Prevention of Abuse and Neglect" showed:

~a report from anyone of patient abuse, neglect, or exploitation shall report the incident to his/her supervisor immediately or in no event later than one hour

~The alleged perpetrator is immediately relieved of patient care duties


Documents titled, "Cornerstone Hospitals of Oklahoma, Muskogee Complaint Log 2016" and "Complaint/Grievance Form" showed patients were not protected during investigations of abuse for five of seven grievances reviewed.


A grievance submitted on 03/17/16 by Patient #21 alleged Staff EE was " ...rude ...gave her a skin tear ..." Investigation took place on 03/24/16; Staff EE continued to work in direct patient care area on 3/21/16, 3/23/16 and 3/25/16.


A grievance submitted on 3/21/16 by Patient #22 alleged Staff EE was " ...rude & abrupt ...feeding me it was too fast & I wouldn't eat that fast & she [Staff EE] said fine then I guess you don't want to eat & put my food away ..." This grievance also showed two staff members reported that Staff EE was being rude & behaving inappropriately on 3/21/16. An investigation took place on 3/24/16; Staff EE continued to work in direct patient care area on 3/21/16, 3/23/16 and 3/25/16.


A grievance submitted on 03/21/16 by Patient #23 alleged Staff CC & Staff EE were " ...very rude and treated him roughly ...one point he was turned & left [with] his face & Lt [Left] arm stuck down in the side of his bed. He was unable to call out, speaking valve not on & call light was under his bed on the floor ... [after] 1 hour [Staff EE] came in and told him to quit banging because she didn't have time to deal [with] him ..." Investigation took place on 03/24/16; Staff CC continued to work in direct patient care area on 03/21/16 and 03/23/16. Staff EE continued to work in direct patient care area on 03/21/16, 03/23/16 and 03/25/16.


A grievance submitted on 05/04/16 by Patient #24's spouse alleged Staff DD of neglect; " ...patient was not turned all day ..." Investigation took place on 05/12/16.


A grievance submitted on 05/09/16 by Patient #25 alleged Staff DD was " ...being too rough ...has an attitude ..." Investigation took place on 05/09/16.


A review of Staff CC employee file showed no documentation of disciplinary action for March 2016 allegations of abuse.


A review of Staff DD employee file showed no documentation of disciplinary action for May 2016 allegations of abuse.


On 03/30/17 Staff B stated any employee with disciplinary actions taken will have documentation located in the employee's file and if any abuse allegations of staff, he/she would be removed immediately.

Based on record review and it was determined the hospital failed to follow their policy and procedures regarding restraints. The hospital failed to verify there is a physician order to utilize restraints; and/or ensure restraints are not used on an as needed basis (PRN) for seven (Patient #4, 10, 12, 13, 16, 19, and 20) of seven patient records reviewed. This failed practice had the potential of restraint misuse, violation of patient's rights, unintended patient injury, new onset of pressure ulcers, and/or decreased self-esteem for all patients admitted to the hospital requiring restraints.


Findings:


Record review of the hospital's "Restraint Reduction Plan" policy showed:


~Hospital staff are to obtain a physician order for restraint, prior to the application of restraint;

~Hospital staff cannot discontinue a restraint intervention and re-start it under the same order, doing so would constitute a PRN (as needed) order;

~A trial release constitutes a PRN use of restraint and is not permitted


The medical record for patient # 4 showed the use of bilateral wrist restraints on 01/17/17 without a physician's order to place the restraints.


Six (Patient #10, 12, 13, 16, 19, and 20) of six medical records reviewed showed physicians order for attempting trial release of restraints and a "Nursing Assessment and Progress Note" for attempting trial release of restraints on every shift.


On 03/30/17, staff B stated staff should ensure a physician order is obtained for restraints and restraints are not to be used as PRN in the hospital. She also stated she was aware the statement "attempt trial release of restraints" was located on the order form for restraints and will have the statement removed from the form.

Based on interview and record review, the hospital failed to use quality and safety data from their performance improvement indicators to improve the services of patients receiving long term care. These failed practices had the potential to increase infection risks to the long term care patients and reduce the hospital's ability to implement best practice standards.


Findings:


On 03/31/17 at 10:00 am, the hospital's document titled, "Strategic Quality Plan" was reviewed. The plan documented the hospital analyzes performance within their "Key Success Factors" to lead them to new opportunities for improvement and leadership would develop plans of actions to bring the hospital in alignment with national standards.


Infection Control

The Infection Control Meeting minutes for 08/16, 10/16 and 12/16 showed standing agenda items, which included the combined infection control data for the main campus and the off-site location, such as ventilation and hospital acquired infections (HAI). The minutes for 12/16 documented 10 HAIs and documented, "Conclusion: Continue following infection protocols. Make sure all staff is adhering to isolation protocol".


Although the minutes for 08/16 and 10/16 contained separate data for Muskogee and Broken Arrow, there was no documented discussion of the data and the conclusion statement was verbatim of the 12/16 minutes.


In the 12/16 minutes, a new disinfectant was submitted for approval and currently in use by the hospital with no evidence the disinfectant was approved by the Governing Body.


Another standing agenda item was water cultures involving dialysis treatments. The "Findings and Conclusions" documented "monthly culture reports to meet or exceed standards. Conclusions: continue to monitor". No data was provided. The conclusion for most standing agenda items were blank or documented, "Conclusion: continue to monitor".


The minutes did not contain analyses of the data provided or discussions and strategies of improvement. The performance improvement data was presented in such a manner as it would be difficult to determine root causes.


Quality Council

The Quality Council Meeting minutes for 03/16, 05/16, and 02/17 showed combined information for the main campus and the off-site location; such as utilization, diagnostic tests, dialysis treatments, emergency medical service transports, patient satisfaction, falls, falls with injury, deaths, medication errors, and code blues. The minutes did not contain analysis of the data provided. The minutes did not contain specific strategies of improvement. The "Conclusions" documented continue improvement, continue to follow protocol, continued diligence in reporting medication errors, blank conclusions, and continue diligence.


In the minutes for 02/17, annual contracted services showed no contracts listed and the "Conclusion" was "completed". The patient satisfaction survey revealed 82% felt pain was managed well, 75 % responsiveness of staff. The conclusion documented "Corporate has a set a new metric goals for patient satisfaction".


In the minutes for 03/16, reported restraint documentation at 50% on charts reviewed. Conclusion: "[Staff Person Name Deleted] and [Staff Person Name Deleted] will check to see why restraint documentation is so low." No subsequent discussion regarding restraint documentation was found. The minutes documented a physician questioned how 30- day readmissions were screened and the discussion was regarding penalties and no discussion of analysis or preventative measures to avoid readmission.


Medical Executive

The Medical Executive Committee Meeting minutes for 02/17 documented physicians, at the Muskogee and not Broken Arrow, were greater than 100 days incomplete for their medical records. The minutes documented these delinquent charts were in direct violation of medical staff policy, corporate policy and state law. The minutes instructed any medical staff that were delinquent to "make a visit to medical records to complete your charts". The hospital's Medical Staff Bylaws were reviewed. The bylaws documented that when physicians have delinquent chart 90 days incomplete their privileges may be considered voluntarily relinquished.


The minutes for 01/17 documented the physician delinquent charts completed and signed by 12/16; yet, during the surveyor's medical record audit 4 of 20 medical record with dates of service from 09/16 to 11/16 failed to be complete. These medical records had multiple missing dates, times, and signature for Patients# 10, 14, 15, and 16.


The minutes documented Quality Improvement Council Summaries and other data, for the main campus and the off-site location data, that included ventilator days, complaints, grievances, medication errors, falls, code blue, combined deaths, and hospital acquired infections.


The minutes documented that the Policy and Procedure "manuals" were presented for approval. No policy table of contents was attached. Staff B stated the hospital had no comprehensive table of contents for the policies. During the course of the survey, all hospital policies reviewed had a date listed, but no approval date. During the course of the survey, the surveyors were provided with two different "Abuse and Neglect" policies and were unable to determine which policy was approved.


The minutes documented a "Compliance checklist" was approved and no attachment was found to determine the elements of this checklist.


Governing Body

On 03/30/17 at 1:45 pm, the Governing Body Meeting minutes were reviewed for February 2017, January 2016, and January through November 2015.


The minutes of 02/17 referenced approved the Medical Executive Committee (MEC) report and its attachments. No date for was listed for the MEC. "TABS" were for reference material, but the specific materials listed were not provided. The minutes documented that clinical policies and procedures were approved, and a TAB was referenced, by no list of policies were provided. The minutes documented that clinical contracts were approved, and a TAB was referenced, by no list of policies were provided.


The minutes for 01/16 documented the Governing Body approval for the 01/16 and 01/15 Quality Improvement Committee Minutes. The minutes were approved and contained no discussion of topics and no attachments. The information and quality information from Medical Executive Meetings were not documented within the Governing Body Meeting Minutes.

Based on interview and record review, the hospital failed to conduct and document quality projects that included designated indicators for both campuses, measurable outcomes, and actions resulting in sustained improvements. This failed practice reduced the hospital's ability to identify patient care issues and to implement best practice standards.


Findings:

A review of Quality Improvement (QI) records showed no documentation of any QI projects.

On 03/30/17 at 9:00 am, the surveyors requested the hospital Quality Improvement Projects for Muskogee and Broken Arrow campuses. The request was for projects in which an improvement need had been identified, actions implemented, and improvements sustained. None were provided.

On 3/31/17 during exit conference, Staff C reported QI projects are not available.

Based on interview and record review, the hospital failed to follow its policies and ensure that a Registered Nurse (RN), functioning as a circulating (intraoperative) nurse, was present during every bronchoscopy requiring moderate sedation and ensure each patient received continuous monitoring by a registered nurse. This failed practice increased the potential of patients having bronchoscopies would not receive continuous monitoring by a registered nurse. Continuous monitoring by the RN is essential during moderate sedation, to observe depth of sedation and cardiorespiratory to avoid risk leading to respiratory depression, hypotension, hypertension, bradycardia, and /or tachycardia.


Findings:


The hospital policy titled, "Moderate Sedation 05/16" showed a monitoring RN must be with the patient at all times and may not engage in tasks that would compromise continuous monitoring during the procedure.


The Oklahoma Board of Nursing's position statement titled, "Moderate (Conscious) Sedation Guidelines for Registered Nurse Managing and Monitoring Patients 05/15" showed that, "the Registered Nurse administering, managing and/or monitoring moderate (conscious) sedation shall have no other responsibilities during the procedure that would leave the patient unattended or compromise continuous monitoring."


The hospital policy titled, "Bronchoscopy 05/16" showed the flexible fiberoptic bronchoscope is a clean, invasive procedure performed by the physician and assisted by the nurse and respiratory care practitioner (RCP). The policy also showed that, "Both the RCP and nurse will monitor the patient during the procedure...The nurse assists the RCP and the physician with resuscitative or diagnostic chores as may be."


On 03/28/17 at 10:45 am, the Respiratory Department was toured.


The Chief Nursing Officer (CNO) stated the hospital provided the service of bronchoscopy procedures with moderate sedation and the physician, who performed the procedure, provided the supervision of an RN. The RN administered moderate sedation, and managed and monitored the patient. She stated a respiratory therapist would also be in the procedure room. The CNO stated the nurse assisted the respiratory therapist as needed and routinely there was no RN exclusively performing the responsibilities of a circulating RN.

Based on record review and staff interview the hospital failed to:

~Ensure the registered nurse (RN) is accountable for and evaluated the nursing care of each patient.

~Follow its policy regarding RN assessment/evaluation of patient care every 24 hours

~Follow its policy and procedures regarding Pain Management


This failed practice had the likelihood for three of 20 patients to have a delay in recognition of changes in the patient's condition by the RN synthesizing patient data to determine rationale for patient care needs and the potential for eleven of 20 patients having poorly controlled pain affecting their psychological and functional status.


A policy titled "Patient Assessment, Reassessment and High Risk Screens" and "Plan for the Provision of Patient Care" showed no evidence of an RN assessment or evaluation for each patient every twenty-four (24) hours.


A policy titled "Pain Management Protocol" showed the Numeric Pain Intensity Scale may be used universally to assess pain ...Wong-Baker Faces Pain Scale may be used for patients unable to comprehend the numeric scale and FLACC Scale for those that are non-communicative. Patient will be reassessed one-half to one hour after administration of pain control treatment, every shift and as needed.


A policy titled "Patient Rights of Management of Acute Pain" showed nursing will use the pain assessment tool to identify pain level.


Oklahoma Board of Nursing Nurse Practice Act defines the RN scope of practice includes assessing the health status of individuals ...analyzing data to determine nursing care needs. The licensed practical nurse (LPN) contributes to the assessment of the health status of individuals ... and participates in the evaluation of responses to interventions.


Oklahoma Board of Nursing Patient Assessment Guidelines shows the comprehensive nursing assessment (initial and ongoing) is conducted by the RN and a focused assessment by the LPN is an appraisal of an individual's status and situation at hand, contributing to the comprehensive assessment by the RN.


On 03/28/17 at 11:32 am, Staff B stated the RN completes an assessment of each patient every 24 hours and usually have an RN assigned to the patient at least every 24 hours.


On 03/31/17 at 10:00 am, Staff D stated initial assessment of pain included asking the patient to rate pain on scale of 1 to 10. To determine effectiveness of intervention Staff B stated would re-assess patient within thirty minutes to one hour. Can reposition patient, review vital signs and tell how the patient is doing, if needed would call physician.


On 03/30/17 at 3:10 pm, Staff B stated nursing staff are required to complete pain assessment every four hours and reassess pain 30 minutes to 1 hour after pharmacological intervention. Expectation is to use pain scale for assessment of pain or identify if the patient is sleeping or resting.


Three (Patients #5, 10 and 11) of 20 medical records showed no documentation of an RN evaluation every 24 hours.


Six (Patients #7, 8, 11, 14, 15 and 16) of 20 medical records showed no documentation of a pain assessment utilizing a pain scale, location, duration, characteristics, precipitators, relief measures or reassessment of pain using a pain assessment tool.


Seven (Patients #1, 3, 6, 7, 9, 11, and 17) of 20 medical records showed no documentation of a complete pain assessment utilizing a recognized pain scale and reassessment within time parameters following pharmacological intervention per hospital policy.

Based on record review and interview, the hospital failed to ensure licensed healthcare providers timely documented the administration of scheduled medications.


This failed practice had the likelihood to result in a change of patient condition for ten of 20 patients (Patient #1, 2, 4, 5, 9, 11, 12, 14, 15, and 16) who did not receive regularly scheduled medications.


A policy titled "Medication Administration Records (MARs)" showed disciplines including nursing and respiratory therapist (RT) will document on the MAR.


Six (Patient #2, 4, 5, 12, 15 and 16) of 20 medical records showed no documentation by the respiratory therapist for administration of scheduled medications.


Seven (Patient #1, 9, 11, 12, 14, 15, and 16) of 20 medical showed no documentation by licensed nursing staff for administration of scheduled medications.


On 03/31/17 at 10:40 am, Staff B stated nursing should document on the MAR after giving scheduled medication. The RT has had difficulty getting the MAR from nursing staff to document their medications so they are documenting on their flowsheet. Staff B stated they are planning a meeting in near future with nursing and respiratory therapy to determine a new process.

Based on record review and interview, the hospital failed to monitor licensed healthcare staff usage of verbal and/or telephone orders. This failed practice had the likeihood for greater error for all patients secondary to problems in interpretation of what someone is saying, distraction and/or noise, and the knowledge, names and pronunciations of drugs leading to an increased risk to patient safety.


A document titled "Medical Staff Bylaws, Rules & Regulations" showed telephone and verbal orders are to be used infrequently.


A policy titled "Physician Orders (Written, Verbal and Telephone)" showed if physician is not present a verbal/telephone order may be taken. Telephone orders should be minimized as much as possible and will be limited to only when physician is not available in hospital. Verbal and/or telephone orders should only be used in case of emergency.


On 03/29/17 Staff B and Staff C stated verbal and/or telephone orders are to be used infrequently when the physician is not available or in cases of emergency.


A document titled "Medical Records" showed data collection of telephone orders for authentication by physician within 48 hours for January through December of 2016. There was no evidence the hospital was monitoring and analyzing the frequency of use for verbal and/or telephone orders.


Eleven (Patient #5, 7, 9, 12, 13, 14, 16, 17, 18, 19 and 20) of 20 medical records "Standard Orders" (Potassium and Magnesium Replacement, Insulin Subcutaneous Sliding Scale Orders, Dietitian Recommendations, Elevated INR Protocol for Patients on Warfarin, Sedation Standing Orders, Phenyleprine (Neo-Synephrine) Continuous Infusion, Routine Admission Orders) showed evidence of frequent use of telephone and/or verbal orders.


Sixteen (Patient #1, 2, 4, 5, 7, 9, 10, 12, 13, 14, 15, 16, 17, 18, 19, and 20) of 20 medical records showed documentation of "Physician Orders" through use of telephone and/or verbal orders were frequently used.

Based on record review and interview, the hospital failed to ensure healthcare providers dated and timed written medical record entries for twenty of twenty patients' medical records. This failed practice had the likelihood for all patients to have inaccurate communication between healthcare providers as the medical record provides a sequential record of patient care promoting patient safety through timely assessments, interventions and ensuring quality patient care.


A document titled "Medical Staff Bylaws, Rules & Regulations" showed all entries into the record shall be dated, timed and authenticated by the person making the entry.


A document titled "Medical Records" which contained data collection of the number of incomplete medical records 30 days after discharge showed no analysis of data or initiation of a quality improvement effort for incomplete medical records falling below threshold for 102 charts which were over one hundred days deficient after discharge and thirty-five (35) charts which were over sixty (60) days deficient after discharge.


A policy titled "Patient Assessment, Reassessment and High Risk Screens" showed initial assessment is done at the beginning of each shift.


On 03/31/17 at 10:35 am, Staff B stated that healthcare providers should date, time and authenticate all entries into the medical record. Quality Improvement Council reviews this for compliance and Health Information Management (HIM) is responsible for capturing this information and following up with physicians after 30 days.


On 03/31/17 at 10:00 a, Staff D stated the purpose of twelve (12) hour and twenty-four (24) hour chart checks are to double check orders, ensure labs are not missed and to look for date, time and authentication of orders. We have color coded stickers on nursing units in baskets used to identify physician signature needed for chart.


Twenty (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, and 20) of 20 medical records showed no evidence of the actual time the full nursing assessment or progress note was completed on the "Nursing: Assessment and Progress Note" and "Progress Notes."


Seventeen (Patient #1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 18) of 20 medical records reviewed showed no time was recorded of when the "Wound Care Report" was completed.


Five (Patient #10, 11, 14, 15, and 16) of 20 medical records showed no date or time for individual entries by each discipline or time of interdisciplinary team meeting on the "Interdisciplinary Team Meeting and Plan of Care".

Based on record review and interview the hospital failed to:

~Ensure healthcare providers dated and timed written physician orders

~Ensure physicians countersigned written orders

~Follow its medical staff bylaws regarding physician orders


This failed practice had the likelihood for all patients' safety to be at risk secondary to confusion among staff when physician orders were written without prompt authentication by physicians of telephone and/or verbal orders.


A policy titled "Physician Orders (Written, Verbal and Telephone)" showed all written orders are to be dated, and timed... must be countersigned by a physician as soon as possible but no later than 30 days.


A documented titled "Medical Staff Bylaws, Rules and Regulations" showed all orders, including telephone orders must be dated, timed and authenticated by the ordering practitioner...Telephone orders must be authenticated within ten (10)days.


A document titled "Medical Records" showed no data analysis for data trending well below hospital threshold or initiation of a quality improvement effort to address this issue for the data collection of telephone orders for authentication by physician within 48 hours for January through December 2016.


On 03/31/17 at 10:35 am, Staff B stated healthcare providers should date, time and authenticate all entries into the medical record. Physicians are aware they should date, time and authenticate telephone and/or verbal orders within ten days. Quality Improvement Council reviews this for compliance and Health Information Management (HIM) is responsible for capturing this information and following up with physicians after 30 days. HIM will provide deficiency letters if needed to physicians who have deficient charts.


Sixteen (Patient #1, 2, 4, 5, 7, 9, 10, 12, 13, 14, 15, 16, 17, 18, 19, and 20) of 20 medical records showed no date and time for when the physician authenticated the telephone and/or verbal orders, per hospital policy, on the "Physician Orders" and "Standing Orders" (Potassium and Magnesium Replacement, Insulin Subcutaneous Sliding Scale Orders, Dietitian Recommendations, Elevated INR Protocol for Patients on Warfarin, Sedation Standing Orders, Phenyleprine (Neo-Synephrine) Continuous Infusion, Routine Admission Orders).


Sixteen (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 12, 13, 14, 15, 16, 17, and 18) of 20 medical records showed no evidence of date and/or time when the order was written by the physician for "Physician Orders."

Based on record review and interview, the hospital failed to demonstrate the development, implementation and approval process for standing orders that included the use of current nationally recognized evidence based guidelines. This failed practice had the likelihood for inconsistencies in patient care and greater risk of medical errors for all patients for which these orders are used secondary to outdated interventions that are not reflective of current evidence based practice, no process to address approval and revisions that included pharmacy, nursing and medical staff, lack of education to provide for successful implementation, and no evaluation of outcomes.


A policy titled "Preprinted and Routine Standard Protocols and Physician Orders" showed no evidence that the standing orders are developed using current nationally recognized evidence based guidelines and an organized process for a multi-disciplinary collaborative effort for reviewing and approval of standard orders prior to presentation to Governing Body. In addition there is no evidence of specific criteria identifying licensed nursing staff within their scope of practice who are authorized to initiate standing orders or specific clinical conditions, situations or diagnoses that would justify the initiation of a standing order.


A document titled "Implementing and assessing an evidence-based electrolyte dosing order form in the medical ICU" dated 2008 showed no evidence that this research is based on current evidence based nationally recognized guidelines and was used in developing the hospital's standing order for potassium replacement.


A document titled "An official ATS statement: Grading the quality of evidence and strength of recommendations in ATS guidelines and recommendations" by the American Thoracic Society dated 2005 was provided to support development of a protocol for elevated INR. There was no evidence that this research was used to develop the hospital's protocol for elevated INR for patients on warfarin.


On 3/29/17 at 3:50 pm, Staff C stated use of evidence based guidelines would not necessarily be in the minutes for Medical Executive Committee and Governing Body Meeting Minutes.


On 3/31/17 at 11:55 am, Staff C stated the "Elevated INR Protocol for Patients on Warfarin" was approved by the cardiologist and this protocol was originally approved by Medical Executive Committee in May 2015, but pharmacy was not included, it was then taken to Governing Body. Staff C was unable to provide annual review by Governing Body.

Based on record review and staff interview, the hospital failed to obtain a properly executed informed consent form. This failed practice had likelihood for patients to receive invasive procedures prior to having adequate information to make an informed decision.


A policy titled "Consent for Medical and Surgical Procedures," showed obtaining informed consent is the responsibility of the physician ...include date and time consent obtained ...signature of professional person witnessing consent ...telephone consent may be accepted with two (2) witnesses.


On 03/31/17 at 10:35 am, Staff B stated that healthcare providers should date, time and authenticate all entries into the medical record. The physician is responsible for explaining procedures to patients.


One (Patient #5) of 20 medical records reviewed titled "Consent for Delivery of Wound Care" and "Blood and Blood Product Administration Consent Form" showed no physician signature, date or time.


Three (Patient #6, 10 and 15) of 20 medical records showed no witness signature, physician signature, date and/or time for insertion of a Peripherally Inserted Central Catheter (PICC) and "Consent for Delivery of Wound Care."

Based on record review and interview the hospital failed to ensure the completion of medical record entries per hospital policy.

A document titled "Medical Staff Bylaws, Rules & Regulations" showed:
~ medical records that are incomplete thirty (30) days after patient discharge are considered delinquent ~thirty (30) days or greater physician will be notified
~letter requiring completion will be sent before sixty (60) days delinquent
~.in delinquent status at sixty (60) days privileges may be suspended
~reach ninety (90) days incomplete privileges may be considered voluntarily relinquished.

A document titled "Medical Records" showed:
· ~No deficiency letters were sent at thirty (30) or sixty (60) days as noted on page 2 as per hospital policy, based on the data collection for the number of incomplete medical records 30 days after discharge
· ~No evidence of analysis of data or initiation of a quality improvement effort for incomplete medical records falling below threshold for 102 charts which were over one hundred days deficient after discharge and thirty-five (35) charts which were over sixty (60) days deficient after discharge.

On 03/31/17 at 10:35 am, Staff B stated healthcare providers should date, time and authenticate all entries into the medical record. Quality Improvement Council reviews this for compliance and Health Information Management (HIM) is responsible for capturing this information and following up with physicians after 30 days. HIM will provide deficiency letters if needed to physicians who have deficient charts.

Based on interview the director of food and dietetics service failed to fulfill all the responsibilities of a service director. This failed practice increased the potential that the accountability of the responsibilities delegated to the Director of Food and Dietetics would be diluted.

Findings:

On 03/28/17 at 10:30 am, the Chief Nursing Officer stated the employed dietitian was functioning in the role of the certified dietary manager.

Staff BB introduced herself as dietary manager. Staff B stated she was currently in school to achieve her certification.

Staff BB stated she shared some service director responsibilities with the dietitian, who was responsible for both hospital's main campus and off-site location. Staff BB stated the shared responsibilities included staff training and quality improvement.

Based on interview and record review, the govering body failed to ensure the designated Infection Control Preventionist was qualified by education, training, experience, or certification. This failed practice of an untrained Infection Control Preventionist increased the likelihood of a suboptimal infection control program for the all patients admitted to this hospital.


Findings:


A review of Staff C, Infection Control Preventitionist's, employee file showed only the core circulum training for infection control.


On 03/30/17 at 1:55 pm, Staff C stated she had additional infection control education and provided documentation of 2.2 hours of infection training and education for pneumonia.

Based on observation, interview , and record review, the hospital failed to ensure:

a.. bronchoscopes were reprocessed according to manufacture's guidelines and nationally recognized guidelines,

b. housekeeping staff adhered to infection control policies in 2 of 2 observations, and

c. dietary aides and patient care technicians adhered to infection control policies and procedures in observations of food tray delivery to the patients in isolation.


Findings:


a. Bronchoscopes

Staff C provided the hospital policy titled, "Cleaning and Disinfection of Equipment, Devices and Supplies 12/16" as the policy regarding bronchoscope disinfection. The policy did not document disinfection instruction for bronchoscopes.


Staff C provided the manufacturer's "Bronchoscope Cleaning Guide" which provided step by step instructions for precleaning and disinfecting bronchoscopes. Step #5 on the guide listed a critical process called "leak testing" to determine if the bronchoscope has any holes in the outer covering or leak at the connections and dials. The process required the use of specific air pump by the manufacturer.


Staff C stated all respiratory therapist had training competency for disinfecting and managing bronchoscopes. During an interview, the Director of Respiratory therapy, Staff O stated he was trained and performed bronchoscopes reprocessing. Staff O demonstrated in simulation the steps of scope reprocessing, and stated instead of using the air pump required by the manufacturer for leak tesing, a syringe was used. (A syringe would not provide the proper air pressure to perform the leak test.)

3 of 3 respiratory therapist employee files, (Staff O, Staff II, and Staff JJ) had "Bronch clean" assessed as passed on a document titled, "Respiratory Annual Competence Verification".


On 03/29/17, the hospital's CEO stated that although bronchoscopy was still part of the services the hospital provided, the hospital had not performed a bronchoscopy since 2015. He stated all patients requiring bronchoscope would be transferred to another hospital, until the leak testing equipment was purchased and the appropriate staff educated on its use.


This failed practice can result in contaminated fluid entering the inside of the scope. Such fluid invasion can result in scope malfunction and is a serious infection control risk for all hospital patients receiving bronchoscopies.


CDC "Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008" documented baterial growth has been found in endoscopes that have been having for 7 days or more.


Staff C stated the hospital did not have a policy regarding reprocessing endoscopes that have hung unused for greater than 7 days.


On 03/29/17 at 10:32 am, during an interview, Staff O stated scopes that have hung unused for greater than 7 days would not be reprocessed prior to use.


This failed practice increased the risk of waterborne bacterial being harbored in endoscopes, which increased the risk for infection for all hospital patients receiving bronchoscopies.


b. Housekeeping


The hospital policy titled, "Personal Protective Equipment (PPE) 12/16 "documented that PPE should be removed at doorway before leaving patient's room and anteroom, and hand hygiene should be performed after removing gloves.


On 03/28 17 at 11:23 am, all hospital nursing units were toured. The nursing units contain one patient on contact isolation and 9 patients on droplet precautions. The type of isolation and required PPE was posted at the entrance of these patiens' rooms.


On 03/31/17 at 10:43 am, a housekeeper was observed preparing to clean a room of a patient on droplet isolation (room 37). Dressed in the same gown mask, and gloves, the housekeeper repeatedly entered and exited the isolation room to get supplies, such as mop, dust pan, and cloths from her cart that was in the hall outside the isolation room. Upon the completion cleaning the room , she mopped the floor trash into the hall and sweep it into her dustpan. The housekeeper pulled the trash in the room and laid it on the floor in the hall before removing the gown, mask, and gloves, walking about four feet into the hall and threw the trash in a second cart. The housekeeper contaminated the lid of the trash cart. The housekeeping then removed her PPE and did not perform hand hygiene.


The Infection Control Preventionist stated housekeeping staff received infection control training. A review of thousekeeper, Staff FF's employee file documented education in PPE, handwashing techniques, isolation procedures, and "review of traffic and work pattern that facilitate containment of infection control.


This failed practice potentially increased the transmission risk of infectious agents to an average of 38 patients daily, staff, and visitors at the hospital.


c. Food tray delivery


The hospital's policy titled, Food Delivery 07/13" was reviewed. The policy documented, "If a patient is in isolation, the employee will follow the directions for entering an isolation room, as printed in the isolation sign.


On 03/28 17 at 11:23 am, all hospital nursing units were toured. The nursing units contain one patient on contact isolation and 9 patients on droplet precautions. The type of isolation and required PPE was posted at the entrance of these patiens' rooms.


During the tour, an overhead page was heard announcing the patients' food trays were delivered. Staff C explained that nurses, patient care teachnicians and dietary aides help distribute the trays to the patients.


On 03/28/17 at 11:58 pm, staff was observed carrying a food tray into a room that had a contact isolation sign on the door and was observed going in and out of isolation rooms without performing hand hygiene.


During an interview, the Infection Control Preventionist, stated employee could step 3 feet within an isolation room without donning PPE. Staff LL stated dietary staff would set food trays for isolation patients on the the sink near the door, and then the staff would carry the tray to the patient.


This failed practice potentially increased the transmission risk of infectious agents to an average of 38 patients daily and staff at the hospital.

Based on interview and record review, the hospital failed to reassess the effectiveness of its discharge planning by:

a. not having policies and procedures to determine the effectiveness its discharge planning process, to include hospital readmissions tracking and analysis,

b. not reviewing, tracking, and analyzing readmissions,

c. not having staff who know how to obtain data on readmissions,

d. not identifying preventable readmissions,

e. not taking actions to address factors identified as contributing to preventable readmissions, and

f. not including readmission analysis in QAPI.

This failed practice has the likelihood to affect all patients receiving services at the hospital and to increase hospital readmissions.


Findings:


On 03/28/17 at 10:45 am, a review of the hospital discharge planning policy, and none was provided.


On 03/28/17 at 9:45 am, Staff C was identified as the Director of Quality Management. Staff C stated patient readmissions were not tracked, and it would be difficult to know what patients were readmitted within 30 days. Staff C provided a document titled, "Case Management" for January & December (no year). The paper was a general case summary and contained no patient identifiers. Staff C stated 30- day readmissions were discussed at intra disciplinary meeting, but no documentation is kept of the discussion. Staff C stated reviewing readmissions for trends and possibly identifying strategies to prevent readmissions was not part of the quality program.

Based on record review and interview, the hospital failed to have a policy that defined imminent death, timely notification and protocol for notifying the Organ procurement organization (OPO). This deficient practice had the potential to prevent the identification of individuals suitable for eye, tissue and organ donation.


Findings:


On 03/31/17 a review of policy #CL-7.3 titled, "Tissue and Organ Donation", showed no definition of imminent death, timely notification or protocol for how the procurement organization would be notified. The Director of Nurses and Quality Manager were asked to provide the policy that defined imminent death, timely notification and protocol for notifying the OPO, none was provided.


On 03/31/17 11:04, the Director of Nurses stated a death packet was to be completed at the time of death. This packet was not mentioned in hospital policy and procedure nor as part of a protocol for timely notification.