HospitalInspections.org

Based on review of the hospital's Quality Assessment and Performance Improvement (QAPI) program data, review of the hospital's "Performance Improvement Quality Oversite Committee Reporting Calendar for 2015", and interview, the hospital failed to incorporate all high risk health care services provided by the hospital into its hospital wide QAPI program. (Generations Labor and Delivery and Neonatal Nursery)
The findings are:
On 08/18/15 at 2:00 p.m., review of the hospital's QAPI meeting minutes dated 01/13/15 through 08/11/15 revealed there was no documentation of any statistical data for its high risk services for its Labor and Delivery services unit and Neonatal Nursery service (Generations). On 08/18/15 at 2:10 p.m., the Director of Quality revealed that each department reports according to the "Reporting Schedule/Calendar" and "only report if there is something that needs reporting".
On 08/18/15 at 2:15 p.m., review of the hospital's "Performance Improvement Quality Oversite Committee Reporting Calendar for 2015" revealed various hospital departments had appointed reported periods but there was no appointed reported period(s) for Generations.

Based on review of the facility policy and procedure and interview, the facility failed to include policies and procedures for non punitive actions towards staff for reporting adverse events to include near misses and close calls.
The findings are:
On 08/18/2015 at 12:40 p.m., review of the hospital's "Sentinel Events or Never Events" and the "Notification Reporting Instructions" showed no evidence that the hospital had adopted policies that support a non-punitive approach to staff when reporting adverse patient events including near misses and close calls. On 08/18/15 at 12:45 p.m., the Director of Quality revealed the hospital policies for staff members who report adverse events does not include information that supports a non - punitive approach for staff who report adverse events to include close calls and near misses. The Director of Quality reported, "Our policy that speaks to non retaliation is in our grievance policy".

Based on review of the hospital's Quality Assessment and Performance Improvement (QAPI) data, review of the hospital's "Quality Plan and Quality Manual", and interview, the hospital failed to show evidence of the amount of resources(funding and personnel) dedicated to the hospital's QAPI programs and the functions for which those resources are used.
The findings are:
On 08/18/15 at 2:00 p.m., review of the hospital's QAPI program revealed there was no documentation showing the allocation of resources to include funding and personnel dedicated to the hospital's QAPI program and the functions for which the resources are used.. On 08/18/15 at 2:06 p.m., the Director of Quality verified there was no hospital data that demonstrated the hospital's allocation of funds dedicated for its QAPI program.

Based on observations, interviews, and review of the hospital's policy and procedures, the hospital failed to ensure its staff used acceptable principles for infection control for: hand hygiene, for disinfecting patient equipment between patients, for transporting soiled linens, for accessing medication vial septum and ports to prevent the cross contamination of potential infectious agents in the hospital setting for 2 of 3 Registered Nurses (RN 1 and 2), 1 of 1 Certified Registered Nurse Anesthetist (CRNA 1), and 1 of 2 environmental services staff (EVS 1), 1 of 2 secretaries observed transporting linen (Secretary 2).
The findings are:
On 08/19/15 at 2:25 p.m., observations of RN 1 showed the registered nurse entered the room of a patient who was on contact precautions. RN 1 placed the hand-held computer that he/she carried into the patient's room on the patient's bedside table. Prior to exiting the patient's room, RN 1 performed hand hygiene and then, retrieved the hand-held computer from the patient's bed side table. After RN 1 exited the patient's room, RN 1 placed the hand-held computer on a counter top, donned gloves, cleaned the hand-held computer, and then placed the hand-held computer back in the same location on the counter top. Observations showed RN 3 retrieved the hand-held computer from the counter and then, transported the hand-held computer to the nursing desk. Then, observations showed Secretary 1 picked up the hand-held computer from the nurse station desk and placed the hand-held computer on the other side of the desk. The hand held computer should have been thoroughly cleaned after removal from the patient's room where contact precautions were in place and prior to its placement on the counter top outside the patient's room.
On 08/20/15 at 9:25 a.m., observations of RN 2 revealed the registered nurse used the hand-held computer at bedside for verification of the patient's medication administration. RN 2 administered the medication to the patient, exited the patient's room wearing the gloves, walked to the nursing station counter, placed the hand-held computer on the counter, removed the gloves, and started documenting. RN 2 failed to remove gloves prior to exiting the patient's room, failed to perform hand hygiene after removing gloves, and failed to disinfect the hand-held computer before transporting the hand held computer to the nurse station counter. On 08/20/15 at 9:45 a.m., RN 3 stated, "I saw the same things that you saw and the gloves were worn out of the room".
On 08/20/15 at 10:05 a.m., observations in PACU 9 revealed Secretary 2 donned gloves, removed the used linens from the bed, and carried the linens in gloved hands to the soiled utility room. Secretary 2 failed to place used linen in a bag prior to transporting the linens to the soiled utility room.
On 08/20/15 at 10:12 a.m., observations in PACU 9 revealed EVS 1 removed gloves, exited the room, walked down the hall, and retrieved linen, but EVS 1 failed to perform hand hygiene after removing the gloves.
On 08/20/15 at 10:45 a.m., observations of CRNA 1 revealed CRNA 1 removed the top from a new medication vial, inserted the needle into the vial septum, withdrew the medication, but CRNA 1 failed to disinfect the rubber septum prior to inserting the needle into the vial septum. On 08/20/15 at 11:45 a.m., observations of CRNA 1 revealed CRNA 1 attached a syringe to the injection port on an intravenous tubing setup, but CRNA 1 failed to disinfect the injection port on the Intravenous (IV) tubing prior to attaching the syringe. On 08/20/15 at 11:50 a.m., observations of CRNA 1 revealed CRNA 1 donned clean gloves, obtained a disinfectant wipe, wiped the handle of the laryngoscope, and then removed the gloves, but CRNA 1 failed to perform hand hygiene after removing gloves. On 08/20/15 at 1:38 p.m., CRNA 1 revealed, "initially when the cap is popped on a new vial, it is considered sterile, and I don't have to clean it. I cleaned the medication port once before in the room, then, I don't clean it again. If I have to do it 10 times, we wouldn't be very efficient. Once, we initially wipe off the port, we continue to give medication through that port".
Hospital policy and procedures, titled, "IV(Intravenous) Push Medications", read, "...5. Cleanse port of tubing closest to venipuncture site with antiseptic wipe and allow to dry...". Hospital policy and procedures, titled, "Using Gloves", read, "...Miscellaneous...2. Used gloves should be discarded into the waste receptacle inside the examination or treatment room...5. wash hands after removing gloves...".

Based on review of the patient records, interview, and review of the hospital policy and procedures, the hospital failed to include evidence of assessing activities of daily living (ADL's) for 1 of 5 patient charts reviewed for discharge planning. (Patient 3)

The findings are:
On 08/17/15 at 2:05 p.m., review of Patient 3's chart revealed the "discharge planning screening tool" showed Patient 3's "usual living arrangement" was with a "residential/assisted living/disability home". The "discharge planning screening tool" failed to include an assessment of Patient 3's ability to perform ADLs or Patient 3's support person's ability to provide self-care. On 08/17/15 at 3:55 p.m., the Director of Quality revealed there was no other documentation for Patient 3 that would show evidence that the ADLs were assessed.
Hospital policy, reads, "....Assessment may include but not be limited to:...3. Patient's baseline ADL function....".

Based on review of the hospital's discharge planning data and interview, the hospital failed to show documentation that it assesses whether or not readmissions were related to inadequate discharge planning.

The findings are:
On 08/17/15 at 1:20 p.m., review of the hospital's discharge planning data showed there was no documentation readmissions that occurred potentially due to problems in discharge planning process. On 08/17/15 at 1:27 p.m., the Director of Quality revealed, "We collect data on readmissions, but I don't think we have any real data that shows the tracking of readmissions, and if the readmission was due to discharge planning".