HospitalInspections.org

Based on interview, record review, and policy review, the provider failed to ensure two of five skilled swing bed patients (12 and 14) had received notice of Medicare non-coverage within two days of their coverage ending. Findings include:

1. Record review of patient 12's electronic health record (EHR) revealed:
*He had been admitted to skilled swing bed on 5/13/22 for intravenous (IV) antibiotics due to an infected wound.
*He was discharged from the hospital on 6/12/22.
*The notice of Medicare non-coverage form had been signed by patient 12 on 6/10/22, but the effective date of services ending field had not been filled in.
-There was no date to support what his last day of Medicare coverage was.

2. Record review of patient 14's EHR revealed:
*She had been admitted to skilled swing bed on 8/10/22.
*She was discharged from the hospital on 8/12/22.
*The notice of Medicare non-coverage form had been signed by patient 14 on 8/10/22, but the effective date of services ending field had not been filled in.
-There was no date to support what her last day of Medicare coverage was.

Interview on 9/22/22 at 8:00 a.m. with swing bed coordinator C regarding incomplete forms revealed:
*She had known the signatures for the end of service needed to be obtained two days before the end of service date.
*She had not ensured the forms had been filled out correctly to include the patients's end date of service.
*Nursing staff would have completed the forms and obtained signatures in her absence.
*Nursing staff should have ensured the forms were filled out to support an end date of Medicare services.
-Ensuring that the end date of service had been filled in.

Interview on 9/22/22 at 9:55 a.m. with director of patient care B regarding her swing bed involvement revealed:
*She attended patient care conferences on Wednesdays.
*She agreed that the Medicare non-coverage forms signed by patients 12 and 14 were incomplete.
*She was not aware they had been incomplete and missing the end of service date.

Interview on 9/22/22 at 2:15 p.m. with administrator A regarding swing bed forms revealed:
*She agreed the forms had not been filled out completely and required an end date of service.
*She agreed patients should have been made aware of their end date of service.

Review of provider's September 2023 policy of termination of Medicare Services Notice of Non-Coverage revealed, "The notice of non-coverage used in transitional care will be issued 48 hours in advance of the provider's decision as to the last day of covered service.

Based on interview, record review, and policy review, the provider failed to ensure:
*Two of two patients (2 and 12) had received a nutritional assessment during their hospitalization.
*One of one patient (2) who was receiving hemodialysis for end-stage chronic kidney disease had been put on a renal diet.
Findings include:

1. Record review of patient 12's electronic health record (EHR) revealed:
*He had been admitted to skilled care from 5/13/22 through 6/12/22 with a diagnosis of osteomyelitis (bone infection) with necrotic (dead) muscle wound.
*He received intravenous antibiotics.
*He had not received a nutritional assessment by the certified dietary manager E or a dietitian consult during his hospitalization.

2. Record review of patient 2's EHR revealed:
*She had arrived in the emergency department on 4/18/22 to be evaluated.
*She had:
-Heart arrythmias.
-Complaints of not feeling well.
-Nausea.
-Itching.
*Her diagnoses included renal failure and on dialysis.
*There was no documentation to support she had:
-Been placed on a renal diet.
-Received a nurtitional assessment by the dietary manager.

Interview on 9/21/22 at 1:30 p.m. with medical director F revealed he would expect anyone who had renal failure and was receiving hemodialysis to be placed on a renal diet.

Interview on 9/22/22 at 9:56 a.m. with director of patient care B revealed:
*Patient 2 should have been placed on a renal diet.
*Some patients refuse to be placed on a renal diet, but that should have been documented in their EHR.

Interview on 9/22/22 at 10:55 a.m. with certified dietary manager E regarding nutritional assessments revealed she:
*Interviewed all admitted patients for nutritional needs.
*Agreed that patient 12 should have had a nutrition assessment and a dietitian consultation due to his wound.
*Had thought that the dietitian had evaluated patient 12.
*Checked for notes from her assessment on patient 12 as well as the dietitian consultation.
-No information had been provided upon exiting the facility.
*Agreed patient 2 was a high-risk patient and should have had a nutritional assessment completed.
*Had been unsure why patient 2 was not placed on a renal diet.

Interview on 9/22/22 at 2:15 p.m. with administrator A regarding nutrition assessments revealed she:
*Agreed that patient 12 should have had a nutritional assessment and a dietitian consultaion due to his wound.
*Agreed patient 2 should have been placed on a renal diet and would have benefited from having a nutritional assessment.

Review of the provider's September 2022 Referrals to the Consultant Dietitian policy revealed:
*The dietary manager will screen all hospital patients within 72 hours of admission.
*After screening, triggers for dietitian consult include:
-Decubiti/Pressure ulcer present
-Swing bed.

Based on observation, interview, record review, and policy review, the provider failed to ensure:
*Transmission-based precautions had been implemented for one of thirty-six sampled patients (1) who had an active clostridium difficile (C.diff) infection [a highly infectious disease] upon admission.
*One of one central sterilization room had been maintained to prevent the potential of cross contamination of infectious material to other patients.
*Two of two emergency department (ED) treatment rooms did not have Yankauer suction attachments opened and connected to suction tubing.
Findings include:

1. Observation on 9/20/22 at 1:30 p.m. of the provider's central sterilization room revealed:
*There was a hopper located in the sterilization room.
-A hopper is a device that holds water and is used to dump patient or clinical material down the drain.
-The device is uncovered and flushes similar to a toilet.
*The hopper was adjacent to an opened shelf that contained the sterilization pouches and wraps.
*There was a Hoyer lift pushed up next to the hopper.
-A Hoyer lift is a device to maneuver patients.
*There was a procedure bed in front of the hopper.
*A wheelchair and walker had been placed adjacent to the hopper.

2. Observation and interview on 9/21/22 at 2:00 p.m. of the central sterilization room with administrator A revealed:
*An open hopper on the wall across from the door to the room.
*An autoclave located at the end of a counter to the left side of the door.
*There were two push carts, one had been labeled "clean" and the other had been labeled "dirty."
*Above the carts was a series of three opened shelves that housed sterilization pouches.
*The hopper was located approximately 4 feet from those supplies and the counter.
*If the hopper was used it would have the potential to spray germ microbes onto the clean designated surface area, shelf contents, and nearby stored equipment.
*That clean counter area was used to handle the sterilized procedure instruments used on patients.
*The room had several pieces of medical equipment stored in it which included:
-An intravenous (IV) fluid pole.
-A wheelchair.
-A procedure bed pushed next to the hopper.
-A Hoyer lift and walker to the right of the hopper.
*Administrator A stated:
-The room had been routinely used for storage of various equipment.
-They had struggled to find a good place to store these things.
-The hopper was functional but had not been used that she was aware of.
-She agreed:
-The hopper could be a source of cross contamination of germ microbes to the equipment stored and the clean work area used to sterilize instruments for procedures on patients.
-Their set-up had not been ideal.
-The room was neither a designated clean nor a designated dirty room.
--They had been trying to find a solution for storage of equipment and the need for a better location for a sterilization room.

3. Observation on 9/20/22 at 1:45 p.m. of the provider's two ED treatment rooms revealed both rooms had opened packages of Yankauer suction attachments connected to suction tubing.

4. Record review of patient 1's electronic health record (EHR) revealed:
*He had arrived at the ED on 7/7/22.
*He was:
-Dehydrated.
-Had been admitted for a "generalized deconditioning."
*The physician's ED note stated he was on oral vancomycin (an antibiotic) for an active C.diff infection.
*He had C.diff listed as an active diagnosis.
*He had remained in the hospital until 7/9/22 until he passed away.
-There was no documentation to support transmission-based precautions had been put in place to ensure staff had not exposed other patients to C. diff pathogens.

Interview on 9/22/22 at 9:56 a.m. with the director of patient care B revealed she:
*Thought patient 1 had been on precautions but that could have been during his previous hospital stay.
*Agreed their central sterilization room needed to have clearly designated clean and soiled areas.
*Confirmed supplies should not be opened ahead of time.

Interview on 9/22/22 at 11:29 a.m. with infection control coordinator D revealed she:
*Agreed patient 1 should have been placed on transmission-based precautions regarding his C.diff infection.
*Stated Yankauer suction attachments should not be opened, as there is the potential for cross contamination of infectious materials to patients.
*Agreed the central sterilization room had lack of separation between clean and dirty areas.

Interview on 9/22/22 at 2:16 p.m. with administrator A revealed she:
*Agreed they need to designate clean and soiled spaces in the sterilization room.
*Stated C. diff. precautions needed to be put in place if someone has an active infection.
*Agreed Yankauer suction tubing should not be attached and open.
-There was the potential for cross-contamination of infectious materials to patients.

Review of the provider's May 2022 Transmission Based Precautions (Isolation) policy revealed:
*"Transmission-Based Precautions are designed for patients documented or suspected to be infected with transmissible or epidemiologically important pathogens for which additional precautions beyond Standard Precautions are needed to interrupt transmission between patients, personnel, and visitors."
*"Transmission of infectious organisms occur when three elements are linked in a chain. Eliminating transmission is accomplished by breaking the chain links. In the hospital, we do this by using transmission based precautions and eliminating the organisms means of transmission."

Review of the provider's August 2021 Standard Precautions policy revealed:
*Soiled care equipment:
-"Should be handled in a manner that prevents transfer of microorganisms:"
-"Physically separate clean from soiled holding areas."