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Based on interview, record review and policy review the facility failed to designate a Director of Activities to provide patient services as required by State and local law. This had the potential to affect all patients in the facility including Swing Bed patients with a census of one and Geriatric Psychiatric Patients in the facility with a census of seven. The facility census was 47.

Findings included:

1. Record review of the State Licensure regulations states the Activity therapy services shall be available with the services provided under the direction of a qualified therapist. All therapy shall be given on the written order of a physician and documented in the patients' clinical
records.

2. Record review of the facility's policy titled, "Description of the Therapeutic Milieu and Treatment Interventions" dated 03/10, stated:
- Patients are assessed by the Occupational and Recreational [Activity] Therapists when ordered on admission to the hospital. Planning for the therapy program is an integral part of the patient's individual treatment plan. The Occupational and Recreational Therapists, with the support of nursing staff, implement the therapy program;
- A wide variety of creative arts are incorporated into the Program's recreational therapy program. Daily recreational therapy sessions may include physical therapy, dance therapy, music therapy, art therapy and a variety of crafts. Crafts may include ceramics, wood projects, leather tooling, and needle crafting.

3. Record review of the facility's Organizational Chart dated 05/13/12 showed no position on the chart for Activities Director.

4. During an interview on 11/26/12 at 2:20 PM, Staff G, Registered Nurse (RN), House Supervisor, stated that patient activities were provided by Staff O, Director of Occupational and Physical Therapy's.

5. During an interview on 11/28/12 at 10:15 AM, Staff O, Director of Occupational and Physical Therapies, stated that she didn't do activities for the patient's but Staff G, RN, House Supervisor, had that responsibility. She stated that patients were provided help with activities of daily living.
Activities of daily living are not considered to be recreational therapy.

6. During an interview on 11/26/12 at 3:30 PM, Staff J, RN, Director of Behavior Health Services, stated that Staff L, Activity Aide, provided activities to all patients in the facility but she had not yet completed the required training as required by the State and planned to complete the training in January next year. She stated that there is a part time contracted employee that oversees Staff L but is not at the facility daily.

7. During an interview on 11/26/12 at 2:40 PM, Patient #2 stated that no one had questioned her about activities, asked for her activity preferences or provided activities on a daily basis. Patient #2 stated that she liked to cook and try new recipes, had a dog and a cat at home that she cared for and liked to go to church.

8. During an interview on 11/28/12 at 11:05 AM, Staff G, RN, stated that he would have to retract his earlier statement and that patient activities were "hit and miss - there is no Activities Director". He stated that Patient #2 had not been assessed for activities even though she was a Swing Bed Patient admitted on 11/17/12 and that she had not been offered any activities.

Based on interview and record review the facility failed to ensure that Contracted Services were evaluated and provided in a safe and effective manner for 55 of 56 Contracted Services. This had the potential to affect all patients in the facility. The facility census was 47.

Findings included:

1. Record review of the facility policy and procedure titled, "Quality Plan" revised 05/23/12 showed no mechanism to evaluate the performance of services provided by Contracted Services. Contracted Services were not included in the facility-wide plan for 2012.

2. During an interview on 11/28/12 at 9:45 AM, Staff F, RN, Chief Nursing Officer (CNO), stated that the dialysis services for all the facility patients are provided by a contracted service.

3. During an interview on 11/29/12 at 2:15 PM, Staff E, RN, Director Quality Assessment and Performance Improvement (QAPI), provided a report titled, "Annual Quality Assessment Performance Appraisal, Contracted Clinical and Clinical Support Services" dated 2010-2011. Staff E stated that she could not provide raw data for the figures and had no idea what criteria, projects, activities or analysis was used to compile the results. She stated that she does not collect data from the contracted services and could only provide evidence of one of the contracted services data reported in the facility-wide QAPI meeting minutes.

Review of the report showed the following:
- Pharmacy: Not returning calls on reported cases in a timely manner, if at all. Too many visits for recurring problems. Not resolving issues when here. Reports not set up correctly or work properly. Not enough help per scheduled upgrade dates to match scheduled help;
- Physician Recruiter: Applicants not always caliber, i.e. Poor references. Monthly report to CEO [Chief Executive Office].

The dialysis contracted service was not listed on the Annual Quality Assessment Performance Appraisal, Contracted Clinical and Clinical Support Services report. Without evidence of raw collected data, data analysis methodology and evaluation, the Annual Quality Assessment Performance Appraisal Report cannot be validated. A facility must be able to show evidence as to the validity of the reported quality data.

Staff E stated that there are no QAPI projects or evaluation for the Dialysis Unit that is a contracted service that provided 24 hour seven day a week dialysis services to the facility patients.

4. During a concurrent interview on 11/29/12 at 2:15 PM, with Staff JJ and Staff E, Staff JJ, RN, Risk Manager, stated that the facility does not have projects or collect data from the contracted services. Staff E, RN, QAPI, stated that the facility had been told about this problem on a previous survey but no changes in the process or procedures for QAPI had been initiated.

Based on interview and record review the facility failed to establish a mechanism to verify evidence of continuing professional medical education (CME) earned by seven of seven physicians (#CC, #DD, #EE, #FF, #GG, #HH, #II) reviewed to ensure the physician was qualified for reappointment to the facility Medical Staff. The facility maintained 129 credentialed physicians who undergo reappointment every two years. The facility census was 47.

Findings included:

1. Review of the facility Medical Staff Bylaws, Article VI: Procedures for Appointment and Reappointment, 6.4 Reappointment Process approved by the Board of Trustees on 07/18/12 showed the following direction:
-Paragraph 6.4 (b) Content of Reapplication Form. The reapplication form and/or application process shall include, at a minimum, updated information regarding the following:
-Paragraph 6.4 (b) (1) Education: Continuing education, training, education and experience during the preceding appointment period that qualifies the staff member for the privileges sought on the reappointment.

2. Review of physician's #CC's, #DD's, #EE's, #FF's, #GG's, #HH's and #II's reappointment applications in their individual credentialing files showed each physician provided a signed statement declaring they had attended CME during the preceding appointment period, however, no listing was provided in any of the credentialing files showing title/topic of the CME, number of credit hours earned, date and time attended or the name of the CME provider.

If provided, the CME education list could assist the credentialing committee and/or any Medical Staff reviewer to accurately assess qualifications of the staff physician seeking reappointment.

3. During an interview on 11/29/12 at 8:22 AM Staff Z, Medical Staff Coordinator stated the following:
-She followed the process for Medical Staff re-credentialing outlined in the current Medical Staff Bylaws.
-She accepted signed statements from each physician requesting re-appointment attesting that physician had attended CME without evidence of topics/titles, when, where, how long or evidence of who provided the CME.
-She had been following the process for the last three or four years.
-Staff physicians were re-credentialed every two years.
-She had never asked any of the facility physicians seeking reappointment for a list of the CMEs attended.

Based on observation, interview and record review the facility failed to provide increased oversight for three (#55, #56 and #57) of nine patients on suicide precautions on the Adult Behavior Health Unit while the patients were provided with moveable furniture and accessible ligature points. These failures had the potential to affect all patients residing in the Adult Behavior Health Unit of the facility with a census of nine. The facility census was 47.

Findings included:

1. Recognized standards of practice for a psychiatric facility include:
The Veteran's Health Administration (VHA) National Center for Patient Safety formed a national committee that developed "The Environment of Care Checklist" for the purpose of reducing environmental factors that contribute to inpatient suicides, suicide attempts, and other self-injurious behaviors. This initiative is consistent with current literature on prevention of suicidal behaviors (Suicide Prevention Strategies: A systematic review. The Journal of the American Medical Association, (JAMA), 2005, v 294, 2064 -2074).

JAMA, published continuously since 1883, is an international peer-reviewed general medical journal published 48 times per year. JAMA is the most widely circulated medical journal in the world.

The VHA and JAMA have established accepted standards of practice for psychiatric inpatient facilities in the United States.

The VHA committee developed the "Mental Health Environment of Care Checklist" (MHEOCC) with the goal to identify and eliminate environmental risks for inpatient suicide and suicide attempts. The following are some of the items included on the MHEOCC to reduce environmental risks for inpatient suicide:
- Institutional faucets will not provide an anchor point for hanging;
- Three point hinges designed and installed so they do not protrude providing an anchor point for hanging;
- All items must be secured to the wall in a manner that prevents removal or use as a weapon or for self-harm. It must be flush with the wall or beveled in a manner so that it cannot be used as an anchor for hanging.

2. Record review of the facility policy titled, "Special Observation S/O, and Constant Observation C/O" dated 03/10, showed the following:
-In order to provide protection to patients, three levels of staff monitoring are provided:
Routine Observation (assess and document at 15 minute intervals),
Special Observation S/0 (assess and document at 15 minute intervals), and
Constant Observation C/O, (staff member constantly with the patient not less than arms length away, and documents at 15-minute intervals);
- Special Observation and Constant Observation may be conducted for clinical reasons that may include; suicidal thoughts, agitation, elopement, risk to self-harm and psychosis;
- Routine Observation: The staff member assesses and documents the patient's status at least every 15 minutes; intervention occurs as needed;
- Special Observation: The staff member assesses and documents the patient's status at least every 15 minutes. Intervention occurs as needed;
- The patient must remain on the Unit;
- The patient is placed in a room close to the nurse's station.
Please note that the facility policy made no delineation between Routine and Special Observations.

3. Observation on 11/26/12 showed one Adult Psychiatric Treatment area with five patient rooms. Each room had two beds, two night tables and one bathroom, sink and toilet. The nurses' station was across from and faces the common patient area and the patient rooms could not be seen from behind the nurses' station. There was no video camera or mirror to visualize the hall where the patient rooms were located.

4. During an interview on 11/27/12 at 10:15 AM, Staff J, Registered Nurse (RN), Director of Behavior Health Services, stated that patients' rooms were always unlocked and patients may go in and out at will.

5. Observation on 11/27/12 at 11:10 AM showed the following:
- All five patient rooms, 254, 255, 256, 257 and 258 had two stationary beds, two moveable bedside tables, two doors with standard hinges providing ligature points and a faucet with two pointed handles and a protruding water spout providing ligature points. Patient #55 assigned to room 254 was on suicide precautions, Patient #56 assigned to room 255 was on suicide precautions and Patient #57 in room 258 was on suicide precautions. No interventions or increased supervision were provided for these high risk patients.

6. Record review of the facility's document titled, "Shift Safety Checklist" undated showed no reference to ligature points or moveable furniture as being a hazard to patients.

7. During an interview on 11/27/12 at 11:20 AM, Staff J, RN, Director of Behavior Health Services, stated that there were three (Patients #55, #56 and #57) of the nine patients on suicidal precautions.

8. Observation on 11/27/12 at 11:20 AM showed no difference in the 15-minute checks for Patients #55, #56 or #57 (on suicidal precautions) than the non-suicidal patients. The 15-minute log was behind the nurses' station and contained pre-printed times for all of the patients on the unit.

9. During an interview on 11/27/12 at 10:55 PM, Staff N, CNA (Certified Nurse Assistant), stated that she always checked the patients every 15 minutes and did not change her pattern, time or method of the 15 minute checks except maybe at lunch time when all the patients are in the common area eating meals.

The practice of checking on patients at the exact same time using the same pattern can inadvertently give patients up to 25 to 30 minutes of time without being detected should they try to commit a self-harm, suicidal act or elopement and wish not to be discovered.

10. Record review of the facility's Behavior Health Unit (BHU) Incident Report for the last 12 months showed 23 observations with the following results:
11 patient falls with injuries and one subsequent death related to the fall;
6 patient to patient altercations with injuries;
1 patient self harm; and
5 other minor injuries documented without known cause.

Based on observation, interview and record review the facility failed to:
-Ensure supplies stored in the Emergency Department and stored in the Respiratory Department were monitored for expiration dates, used or discarded prior to expiration date and not accessible for patient use after the expiration date indicated on the label.
-Maintain adequate surgical equipment inventory for orthopedic (bone/joint) cases that provided adequate time to sterilize and decontaminate instruments according to acceptable standards of practice. The facility used Immediate Use Steam Sterilization (IUSS) or Flash Sterilization which shortened the decontamination process. Flash Sterilization may increase the risk of ineffective decontamination and the risk of transmission of infectious agents. Ineffective decontamination placed surgical patients at a greater risk for infection. The facility surgical staff performed an average of 229 surgical cases a month and an average of 44 orthopedic (bone) cases a month. The facility census was 47.

Findings included:

1. Observation on 11/27/12 at 11:00 AM in the Respiratory Department supply room showed staff stored packaged, dated trach (or tracheostomy, a surgically made hole that goes through the front of the neck and into the trachea, or windpipe, to help breathing) vent filters (gauze and cotton, cigar shaped plug used to insert in a trach so the patient can move freely to shower, etc.) in a bin on a shelf. Further observation showed the following dates:
-One trach vent filter dated expired 03/2002.
-Fourteen trach vent filters dated expired 07/2008.
-Approximately twelve trach vent filters dated expired 06/2010.
-Approximately twenty four trach vent filters dated expired 06/2011.

2. During an interview on 11/27/12 at 11:00 AM Staff S, Director of Respiratory stated the following:
-The Respiratory Department maintained eight respiratory therapists on staff plus five registered respiratory therapists who worked on an as needed basis.
-All respiratory staff had access to the supplies in the Respiratory Department supply room for use with patients.
-He had been in position as director for about two months.
-The staff person responsible for inventory of Respiratory Department supplies was the department director (Staff S himself).
-He planned to perform the first inventory of department supplies on Friday (11/30/12).
-He was not aware of the expired trach vent filters stored on the shelf.
-He did not have a respiratory policy and procedure regarding inventory of supplies or checking for outdated supplies.

3. Observation on 11/26/12 at 2:30 PM of crash cart #2 (a set of trays/drawers/shelves on wheels used to transport and dispense emergency medication/equipment at the site of a medical emergency) in the Emergency Department (ED) showed one catheter 18/20 gauge expired 04/2001 and one catheter expired 04/2006.

Observation on 11/26/12 at 3:35 PM in the ED supply room showed six packaged trach vents with expiration dates of 6/10.

4. During an interview on 11/26/12 at 3:50 PM Staff JJ, Registered Nurse, stated that the supply room was checked for expired supplies monthly. She stated that if trach vents were needed; they were available from central supply or the Intensive Care Unit (ICU). She stated that it would take staff about two minutes for staff to go to ICU to obtain one.

5. During an interview on 11/26/12 at 2:35 PM, Staff B, Registered Nurse (RN), Operating Room (OR) Nurse Manager stated that the OR department followed the Association of Peri Operative Registered Nurses (AORN) standards.

6. Record review of the facility's policy titled, "Sterilization in the OR" dated 08/2012, showed direction that sterilization in the OR would be kept to a minimum and was not to be used as an alternative to purchasing additional instruments.

Record review of the facility's policy titled, "Processing and transportation of sterile instruments and sets" dated 08/22/12, showed that all sterile reprocessing of instrument trays and sets should be accomplished by the Central Sterile staff following guidelines set forth by AORN, Association of the Advancement of Medical Instrumentation (AAMI), and approved hospital policy.

Review of the 2012 AORN Peri Operative Standards and Recommended Practices showed direction for staff to keep the use of flash sterilization/Immediate Use Steam Sterilization (IUSS) to a minimum. Flash sterilization may be associated with increased risk of infection to patients because of pressure on personnel to elimination one or more steps in the cleaning and sterilization process.

7. Review of the 2012 OR IUSS log for the past six months showed the following:
-May: 40 Orthopedic cases, 12 (or 30%) of these cases had instruments used that required IUSS sterilization processing.
-June: 47 Orthopedic cases, 16 (or 34%) of these cases had instruments used that required IUSS sterilization processing.
-July: 50 Orthopedic cases, 16 (or 32%) of these cases had instruments used that required IUSS sterilization processing.
-August: 36 Orthopedic cases, 15 (or 41%) of these cases had instruments used that required IUSS sterilization processing.
-September: 43 Orthopedic cases, 11 (or 25%) of these cases had instruments used that required IUSS sterilization processing.
-October: 50 Orthopedic cases, 7 (or 14%) of these cases had instruments used that required IUSS sterilization processing.

8. During an interview on 11/26/12 at 2:35 PM, Staff B, RN, stated that immediate use sterilization processing should be used minimally and that the OR needed at least one more complete orthopedic instrument set.

9. During an interview on 11/28/12 at 9:50 AM, Staff P, Central Sterile Manager, stated that the facility needed another orthopedic instrument set for arthroscopy (joint) cases. Staff P stated that they don't have enough orthopedic instruments on busy days and that IUSS processing of instruments had to be done on busy days.

10. During an interview on 11/29/12 at 8:45 AM, Staff X, Orthopedic Surgeon, stated that the facility should only use IUSS sterile processing for a one of a kind, dropped instrument. Staff X stated that IUSS processing was a concern and was not the preferred method of sterilization.

11. During an interview on 11/29/12 at 10:30 AM Staff AA, Infection Control manager, stated the obvious concern with doing IUSS processing was post operative (after surgery) infections.


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Based on observation, interview and policy review the facility failed to ensure:
-Staff follow the facility's hand hygiene policy when staff did not perform hand hygiene between glove changes for one patient (#28) of four patients observed and did not follow the facility policy related to personal protective equipment (PPE, disposable gloves, gowns) for four patients (#2, #47, #52 and #54) of four patients observed;
-Dietary staff followed appropriate techniques for tray service to one of one patient (#54) in isolation.
-Dietary staff followed appropriate infection control techniques for items dropped on the floor. This could affect all patients receiving food trays. The facility census was 47.

Findings included:

1. Record review of the facility's policy titled, "Hand Hygiene Policy" revised 02/12 (February, 2012), stated the following:
-Hand hygiene was considered the single most important procedure for preventing healthcare acquired infections. Bacteria were easily spread in the hospital environment from patient to patient via the hands of healthcare workers. Any contact with the patient or the patient's environment could conceivably result in the transfer of microorganisms to the hands. Following standard precautions and avoiding contamination of the hands was essential in helping to prevent the spread of microorganisms. When hand hygiene was necessary, personnel would follow hand hygiene practices in accordance with the following current CDC [Centers for Disease Control and Prevention] and APIC [Association for Professionals in Infection Control and Epidemiology] Guidelines;
-The purpose of hand hygiene was to remove dirt, organic materials, and transient microorganisms or to reduce resident flora based on the activity to be performed. Hand hygiene was only part of a comprehensive approach to providing the patient with a sanitary environment thus reducing the risk of infection;
-Indications for hand hygiene: Before and after contact with each patient; after contact with patient intact skin; after contact with inanimate environmental sources likely to be contaminated; after removing gloves;
-Other aspects of hand care and protection (Glove use): Gloves should be used as an adjunct, not a substitute for handwashing; gloves should be changed, and hand hygiene performed after using gloves for contaminated activities; gloves should be changed and hand hygiene performed between patient contact.

2. Observation on 11/27/12 at 10:15 AM showed Staff V, Registered Nurse (RN), in order to remove an indwelling Foley catheter (a tube used to drain urine from the bladder) of Patient #28 performed hand hygiene and donned gloves. He then removed the gloves to obtain paper towels to place under the patient and in doing so touched the perineum (the area which includes the vagina) of the patient. He donned gloves without performing hand hygiene which increases the probability of infection by spreading bacteria. He removed the indwelling Foley catheter and wearing the same gloves proceeded to rearrange the patient's covers.

Hand hygiene should be performed between all glove changes, before and after contact with each patient and before touching any inanimate objects such as the covers of the patient.

3. During an interview on 12/03/12 at 10:00 AM, Staff V, RN, stated that he did not perform hand hygiene after removing his gloves to obtain the paper towels and did not remove his gloves and perform hand hygiene after touching the patient and before rearranging the patient's covers. He stated that he should have.

4. Observation on 11/27/12 at 8:40 AM showed Staff M, RN, did not perform hand hygiene before donning gloves during medication pass for Patient #2. She then removed her gloves but did not perform hand hygiene. Staff M touched the patient's skin, took a blood pressure reading, touched the bed clothes, bedside table, and medication cup. Without performing hand hygiene Staff M donned another pair of gloves and applied Granulex (medication for wound care) to the patient's heels. Staff M removed the gloves and did not perform hand hygiene.

5. During an interview on 11/27/12 at 3:10 PM, Staff M stated that she didn't realize she had to perform hand hygiene before and after gloving. She stated she would have to review the Hand Hygiene Policy to refresh her memory.

6. Review of the facility's policy titled, "Contact Precautions" dated 02/2012 (February, 2012) showed the following direction:
-Policy: a. Specific Requirements: iv. A sign indicating that the patient is on contact precautions should be placed in a clearly visible location outside of the patient's room.
-Policy: a. Specific Requirements: v. Gloves must be worn when entering the room of a patient on contact precautions.
-Policy: a. Specific Requirements: vii. Gloves are to be removed before leaving the patients environment.
-Policy: a. Specific Requirements: viii. Perform hand hygiene immediately following glove removal.
-Policy: a. Specific Requirements: x. Wear a gown when entering the room if it {is} anticipated that clothing will be soiled or have contact with the patient or the patient's environment.
-Policy: b, Conditions/Diseases Requiring Contact precautions: {list included} Clostridium difficile.

7. Observation on 11/27/12 at 3:15 PM, showed Staff T, RN, donned PPE (personal protective equipment e.g. gown, gloves, mask) to enter Patient #52's room who was on contact isolation for MRSA (Methicillin-resistant Staphylococcus Aureus, a bacteria that has become resistant to antibiotics normally used to treat infections). Staff T did not tie the PPE gown at the waist allowing the gown to open and touch the patient's bed, bedside table and sink while helping the patient onto the bedpan. Staff T reached into his pocket, under the PPE gown, retrieved his cellular telephone with his gloved hand and used the telephone. Staff T did not clean the telephone before or after use and replaced the telephone into his pocket under the PPE gown, removed the PPE, washed his hands and exited the room.

8. Observation on 11/29/12 at 8:00 AM in the Dialysis room, Staff Y, RN, prepared Patient #47 for a dialysis treatment. During the observation with the patient from 8:25 AM to 10:09 AM, Staff Y donned gloves five times without hand hygiene performed and removed gloves six times without hand hygiene performed.

9. Record review of current Patient #54's admission history and physical showed the patient was admitted on 11/26/12 with diarrhea and diagnoses including Clostridium difficile colitis (infection of the colon caused by an over growth of a bacteria, Clostridium difficile usually associated with antibiotic use).

10. Review of an undated copy of the facility's "Patient and Family Education Regarding Clostridium Difficile Infection (CDI)" provided during the survey showed the following direction:
-Everyone who enters your room must wear gown and gloves.
-Wash hands with soap and water.
-Since Clostridium difficile is an organism found in feces, use of traditional hand washing is preferred.

11. Observation on 11/27/12 at 11:50 AM in the 1 East Unit corridor showed the following:
-The door to Patient #54's room was opened.
-Unit staff had taped isolation signage on the door however it was not easily seen from the hallway because the door was opened.
-Staff E, Chief Quality Officer and RN entered Patient #54's room without wearing disposable gown, performing hand hygiene or gloving.
-Staff E provided bedside care to Patient #54.
-Staff R, Diet Aide passed patient meal trays and failed to wear a disposable gown, perform hand hygiene and glove before delivering a meal tray to Patient #54.
-Staff R entered Patient #54's room placed the tray on the over bed table and exited the room.
-Staff R failed to perform hand hygiene and continued to pass the remaining trays in the diet cart to other patients on the unit.
-Staff R dropped a strip of three individually packaged disposable hand sanitizers on the floor, retrieved the strip of packets and placed them on the top of the food cart.
-Staff R continued to pass individual meal trays and placed one of the disposable hand sanitizers on each tray.

12. During an interview on 11/27/12 at 10:03 AM Staff AA, Infection Control/Employee Health nurse stated the following:
-The door of the isolated patient's room should be closed.
-A dietary staff entering an isolation room without gown, gloves and hand hygiene was unacceptable.
-Dietary staff should not enter the room of a patient on isolation.
-Dietary staff should not pick up any items from the floor then, place those items on a patient's meal tray.
-Staff E should have worn a gown, performed hand hygiene and put on gloves before entering Patient #54's room.





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