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Based on record reviews, interviews, and review of the hospital's policies and procedures, the hospital governance failed to ensure that the medical director for the hospital's acute dialysis unit assessed and reviewed the dialysis unit's monthly culture reports for March 2017, April 2017, and May 2017.

The findings are:

On 5/31/17 at 2:30 p.m., review of the dialysis monthly culture reports revealed the medical director had not signed the reports for March 2017, April 2017 or May, 2017. Review of the March 2017 report revealed a note that stated, " MD(Medical Doctor) to sign off during QAI(Quality Assurance) on 4/28/17", but the cultures were not authenticated. The findings were verified with the Quality Coordinator on 5/31/17 at 2:30 p.m. at the time of the review.

Hospital policy, titled, "# 3.1, Content/Documentation Requirements", reads, "....Authentication: 1. The attending physician shall sign all reports he/she generates, including orders and notes....".

Based on record reviews and interview, the hospital failed to ensure the hospital's governance completed a 3 year projected budget.

The findings are:

At approximately 1:30 p.m. on 05/30/17, the hospital presented the hospital's current budget, but the budget data had no documentation of a 3 year projected budget. In an interview on 06/01/17 at 3:48 p.m., the hospital Quality Coordinator confirmed the hospital did not have a 3 year projected budget.

Based on record reviews, interviews, and review of the hospital's policy and procedures, the hospital failed to ensure physician orders were followed for fasting blood sugars for 3 of 15 inpatient charts (Inpatient 8 and 13), failed to follow physician ordered blood flow rates for the dialysis treatment for 1 of 15 patient charts reviewed for nursing services (Patient 14), ensure staff followed its policies for conducting the water quality testing in the dialysis unit, and ensure staff complete hospital logs for safety checks, and failed to obtain and document the patient's vital signs for 3 of 15 patient charts and 1 of 10 closed charts reviewed reveiwed for care and services. (InPatient 13, 14, 15) and (Closed Record Patient 2), and failed to docuement pre and/or post assessment of 4 of 15 inpatient charts. (Inpatient 9. 12. 13. and 14)


The findings are:


On 5/30/17 at 3:18 p.m., observations in the hospital's acute dialysis unit revealed the Clinical Certified Hemodialysis Technician (CCHT 1) conducting the total Chlorine/Chloramine testing of the RO (Reverse Osmosis)water. CCHT 1 obtained one hundred (100) milliliter (ml) water sample from the portable reverse osmosis (RO) tank, swished the test strip for 45 seconds in the water, shook the excess water off of the strip, and had the nurse verify the result 4 minutes later. In an interview with the CCHT 1 at 3:23 p.m., CCHT 1 explained the step by step process as " We swish the strip for 30 seconds, shake it twice, and then read and record the results after 2 seconds."

On 5/30/17 at 3:35 p.m., Registered Nurse (RN) 4 explained the process for testing the the quality water for Chlorine and Chloramines as "We use the 1 minute swish, shake it, and then read the results 20 seconds later. I'm not sure why she did it that way, and she is our most experienced technician here."

Hospital Procedure, titled, "FMS-CS-IC-II-140-205C, Total Chlorine Testing using the RPC Ultra Low Total Chlorine Test Strips Procedure", reads, "....2....collect a fresh 100 ml sample of water in a plastic sample cup....3. Remove one test strip from its foil package and dip in the sample for 60 seconds....4. Remove the strip and shake once, briskly, to remove excess water....5. Wait 20 seconds for the test strip color to develop....6. After the 20 second wait period, immediately compare the strip color to the K100-0118F color chart to determine the Total Chlorine level in the sample....".

On 5/31/17 at 10:40, observations in the medication room revealed the Dysreflexia Tray List ("check to be completed every 24 hours"), had not been completed on 5/9/17, 5/11/17, 5/12/17, 5/14/17, 5/15/17, 5/18/17, 5/19/17, 5/20/17, 5/22/17, 5/23/17, 5/24/17, 5/25/17, 5/26/17, 5/27/17, and 5/28/17. The findings were verified with RN 9 and the Quality and Risk Director at the time of the observations.

On 5/31/17 at 11:28 a.m., review of Inpatient 8's medical record revealed the patient was admitted on 5/22/17. There were documented finger stick blood sugars prior to meals and at bedtime, but there was no physician order for the blood sugars. In an interview with the Quality and Risk Director at 11:58, the Director stated,"The order should be here somewhere, but when the blood sugar is checked by the staff that actually initiates the order." On 5/31/17 at 12:05 p.m., RN 2 revealed, "There is an order set that includes orders for fingersticks, and the order is not here. It could be put in manually, but it's not here either."

On 5/31/17 at 12:18 p.m., review of Inpatient 9's medical record revealed the patient was admitted on 5/22/17, and received ordered pain medications on the following days and nursing failed to document pre/post pain assessments:
On 5/23/17, the patient was administered 1 Norco 5 mgs(milligrams) -325 mgs tab at 0753 a.m.. The pre - assessment for pain level was documented as a "5". There was no post pain assessment documented .
On 5/24/17, the patient was administered 1- Norco 5 mgs-mg tab at 9:03 a.m. The pre - assessment for pain level was documented as a "5". There was no post pain assessment documented.
On 5/24/17, the patient was administered 2- Norco 5 mgs-325 mgs tabs at 1:08 p.m. The pre - assessment for pain level was documented as a "7". There was no post pain assessment.
On 5/26/17, the patient was administered 1 Norco 7.5 mgs-325 mgs tab at 6:04 p.m. The pre- assessment pain level was documented as a "5". There was no post pain assessment.
On 5/30/17, the patient was administered 1- Norco 7.5 mgs-325 mgs tab at 1:12 p.m. The pre - assessment pain level was documented as a "5". There was no post pain assessment.
On 5/31/2017 at 12:18 p.m., the findings were verified with the Director of Quality and Risk at the time of the chart review.






27380

Based on record reviews and interviews, the hospital failed to ensure physician orders were followed for patients receiving finger stick blood glucose procedures and for dialysis patients receiving dialysis treatments in the hospital's dialysis units.


The findings are:


Review of Inpatient 13's chart on 06/01/17 at 8:15 a.m. revealed physician orders for Finger Stick Blood Sugar (FSBS) tests three (3) times a day before meals (TID AC). Review of FSBS data in Patient 13's chart revealed FSBS tests were completed on 05/28/17 at 7:23 p.m., on 05/29/17 at 9:04 p.m., on 05/30/17 at 9:58 p.m., and on 05/31/17 at 8:34 p.m. which were outside the parameters in the physician orders. In an interview on 06/01/17 at 3:46 p.m., the Quality Coordinator confirmed the FSBS tests for Patient 13 had been conducted without a physician order and routine FSBS testing should not be done without a physician order. Review of Inpatient 13's chart on 06/01/17 at 10:50 a.m. revealed FSBS tests were completed yielding critical values with no documentation of notification to a physician on 3 occasions. On 05/29/17 at 9:04 p.m., Patient 13 had documentation of a glucometer reading of 302, on 05/30/17 at 9:58 p.m., the glucometer reading was documented as 365, and on 05/31/17 at 8:34 p.m., the glucometer reading was documented as 305. There was no documentation that the physician was notified of the elevation in the patient's glucose level. In an interview on 06/01/17 at 3:15 p.m., the Quality Coordinator confirmed the critical FSBS tests were completed, and there was no documentation that the results were reported to the physician. The Quality Coordinator also stated the hospital did not have a Hyperglycemia protocol for staff to follow.

Review of Inpatient 14's dialysis record for 05/25/17 revealed there was a physician order for a blood flow rate (BFR) of 350 milliliters/minute (ml/min). Review of the dialysis treatment flow sheet revealed the BFR was recorded as 400 ml/min from 1:50 p.m. until 4:30 p.m.. There was no documentation on the patient's dialysis treatment record indicating why the BFR was increased from 350 ml/min to 400 ml/min. In an interview on 05/31/17 at 4:19 p.m., Certified Clinical Hemodialysis Technician (CCHT) 1 confirmed the physician ordered BFR for the patient's dialysis treatment was 350 ml/min, but the patient's dialysis treatment ran at 400 ml/min. CCHT 1 confirmed there was no documentation why the BFR was increased, and there should have been a note explaining the change in the BFR.

Review of Inpatient 12 on 05/31/17 at 12:34 p.m. revealed Patient 12 had no vital signs documented on 05/27/17 at 8:00 a.m. and 2:00 p.m., 05/28/17 at 8:00 a.m., 2:00 p.m., and 8:00 p.m., 05/30/17 at 8:00 a.m. and 8:00 p.m., and on 05/31/17 at 8:00 a.m..

Review of Inpatient 13's chart on 05/31/17 at 12:10 p.m. revealed Patient 13 had no vital signs documented on 05/26/17 at 3:07 p.m., 05/27/17 at 2:00 p.m., 05/28/17 at 8:00 a.m., 2:00 p.m., and 8:00 p.m., 05/30/17 at 8:00 a.m. and 2:00 p.m., and on 05/31/17 at 8:00 a.m..

Review of Inpatient 14's chart on 05/31/17 at 11:24 a.m. revealed Inpatient 14 had no vital signs documented on 05/26/17 at 8:00 a.m. and 2:00 p.m., 05/27/17 at 8:00 a.m., 2:00 p.m., and 8:00 p.m., 05/28/17 at 8:00 a.m., 2:00 p.m., and 8:00 p.m., and on 05/31/17 at 8:00 a.m..

Review of Inpatient 12's chart on 05/31/17 at 12:34 p.m. revealed Inpatient 12 had no documentation of adult pain assessments on 05/27/17 at 8:00 a.m., 05/28/17 at 8:00 p.m., 05/30/17 at 8:00 a.m. and 8:00 p.m., and on 05/31/17 at 8:00 a.m. while receiving scheduled pain medication.

Review of Inpatient 13's chart on 05/31/17 at 12:10 p.m. revealed Inpatient 13 had no documentation of adult pain assessments on 05/26/17 at 8:00 p.m., 05/27/17 at 8:00 a.m., 05/28/17 at 8:00 a.m., and on 05/31/17 at 8:00 a.m. following the administration of as needed pain medication. On 05/29/17, documentation showed Inpatient 13 received 2 as needed doses of Percocet 5/325 (2) tablets at 6:43 a.m. and 5:22 p.m. and no follow up pain assessments were documented.

Review of Inpatient 14's chart on 05/31/17 at 11:24 a.m. revealed Inpatient 14 had no documentation of an assessments for pain following the administration of as needed pain medications on 05/26/17. Inpatient 14 received an as needed dose of Tramadol 50 milligrams (mg) at 8:55 a.m., and there was no documentation of a follow up pain assessment. On 05/27/17, Inpatient 14 received an as needed dose of Tramadol 50 mg at 6:17 a.m. and a follow up pain assessment was not completed. On 05/28/17, Inpatient 14 received an as needed dose of Tramadol 100 mg at 10:39 p.m. and a follow up pain assessment was not completed. On 05/31/17, Inpatient 14 received an as needed dose of Tramadol 100 mg at 5:56 p.m. and a follow up pain assessment was not completed.

In an interview on 06/01/17 at 2:47 p.m., the hospital Quality Coordinator confirmed the Inpatient records for Inpatient 12, 13, and 14 had no documented assessments of the patient's pain after administration of the patient's ordered pain medication.

Review of hospital policy, titled, "COP (Care of Patient) - 2029 in section O number 5", revealed, "Chart pain level after implementation of intervention."



38774

On 06/01/17 at 10:25 a.m., review of the closed record for Patient 2 revealed no vital signs were documented for the patient on 05/21/17. Review of the physician's orders revealed a physician order that read "Vital signs BID(twice a day)." On 06/01/17 at 11:13 a.m., the findings were verified by the Director of Case Management.

Based on observations, interview, and review of the hospital policies and procedures, the hospital failed to ensure medications were kept secure at all times for 1 of 3 medication carts observed in the hallway.


The findings are:


Observations in the hallway on 06/01/17 at 6:47 a.m. revealed a nursing cart outside of a patient room that was unattended. The bottom drawer of the cart was partially open. At 7:03 a.m., Registered Nurse (RN) 7 walked by the cart and was asked to confirm the bottom drawer was open and to fully open the drawer. RN 7 confirmed the drawer was partially opened and opened it fully revealing a drawer full of syringes. RN 7 shut the drawer and locked the cart. RN 7 was asked to open the cart again and leave the bottom drawer partially open as before. With the bottom drawer partially open, the machine did not automatically lock and it was possible to open the top left drawer which contained Heparin. RN 7 confirmed the upper left drawer contained Heparin and then shut and locked the cart. At 7:05 a.m., RN 8 revealed he/she was the person who had left the drawer open because she was doing finger stick blood tests and didn't think she needed to close the drawer. RN 7 confirmed that medication carts were to be locked at all times.

Review of the hospital policy for safe storage of medications, titled "Pharm 307, MM.03.01.01", revealed, "Med carts are self locking and are locked whenever it is not being used by the nursing staff." In an interview on 06/01/17 at 7:32 a.m., the Nurse Manager and RN 6 confirmed the medication cart should be fully locked at all times.

Based on observations and interview, the hospital failed to ensure expired patient supplies were removed from the patient care areas. (Radiology Procedure Room, Dialysis Unit, and high control solutions for the glucometer )

The findings are:

On 5/30/17 at 1:30 p.m., random observations in the Radiology Procedure Room revealed (1) bottle of E-Z Disk 700 mgs (milligrams) (Barium Sulfate Tablets)/100 tablets per bottle marked expired 7/2016, but remained on the shelf with other bottles of medications. On 5/30/17 at 1:39 p.m., the Director of Rehabilitation 1 verified the findings.





27380

Observations of the high control solutions for the glucometer in use on 06/01/17 at 7:18 a.m. revealed there were 3 open containers of solution on the cart. The first container was marked with an opened date of 03/10, the second container was marked with an opened date of 05/29, and the third container had no opened date marked. In an interview on 06/01/17 at 7:34 a.m., the Nurse Manager, and Registered Nurse (RN) 6 confirmed the bottles should be labeled fully with the month, day, and year the bottles were opened and the 3 high control test bottles had not been labeled correctly.



31672

On 5/30/17 at 2:50 p.m., observations in the Acute dialysis supply closet revealed a canister of blood leak strips not labeled when opened and a half full gallon jug of 2.0 Potassium (K+) 2.5 Calcium (Ca++) acid concentrate not labeled when opened.

On 5/30/17 at 3:00 p.m., observations in the Acute dialysis unit revealed two (2) 3 gallon jugs of Bicarbonate mixture that had not been labeled with initials, date, or time. The findings were verified with the Clinical Certified Hemodialysis Technician (CCHT) at the time of the observation. CCHT 1 stated,"Per our policy, it should be labeled with a date and time. I just made it before you came in. I forgot to label it." On 5/30/17 at 3:30 p.m., the findings were verified with the Chief Biomedical Technician.

Hospital policy, titled, FMS-CS-IC-II-140-301A, Mixing Bicarbonate in a Single Concentrate Jug", reads, "....the Bicarbonate concentrate solution mixed in single jugs must be labeled for use with single jugs....".

Based on observations, interviews, and review of the hospital's policy review, the hospital failed to ensure that sugar and rice were stored in approved sanitary storage containers and failed to ensure that milk served from the tray line was maintained at 41 degrees Fahrenheit or below in 1 of 1 kitchen observed.

The findings include:

Observations in the kitchen during the initial tour on 5/30/17 at 1:20 p.m. revealed a large bin containing rice sitting on the bottom shelf. The bin was observed to be covered with saran plastic wrap while the other bins had bin covers attached to the bins. Staff indicated that the cover was broken but that one cover was ordered. Review of the facility email record dated 3/3/17 revealed that the lid that was ordered was the wrong size. The email noted that the lid was special ordered and could not be returned. There were no further documents or email(s) presented during the survey to verify that there was any further follow up on obtaining a lid for the rice container between 3/3/17 and 5/30/17. Observations in the kitchen on 6/1/17 at 6:42 a.m. and 9:17 a.m. revealed the rice bin covered with aluminum foil. Observations at 9:17 on 6/1/17 revealed a large bin with sugar that had a cracked lid with a piece missing at the right lip of the lid. Dietary Staff 19 verified the finding, threw the lid away, and covered the bin containing the sugar with aluminum foil. In an interview with Dietary Staff 19 on 6/1/17 at 6:19 a.m., Dietary Staff 19 revealed the lid that was ordered for the rice bin but was the wrong size and could not be returned. Dietary Staff 19 stated that a new rice bin would have to be purchased. Dietary Staff 19 verified that all bins should be securely covered.

Review of hospital Policy NS D-11, titled, "Food Storage", revised on January 2017, reads at Policy 8, "All food stock and products are stored in NSF approved sanitary storage containers, or food quality plastic bags, covered, labeled as to contents and dated."

Observations of the preparation of the breakfast meal on 6/1/17 at 6:15 a.m. revealed milk cartons on several trays on the tray line. A sampling of 3 milk cartons were checked with the thermometer and was found to be at 45 degrees Fahrenheit. In an interview with Dietary Staff 19 on 6/1/17 at 6:30 a.m., he/she verified the findings. Staff 19 revealed cold foods should be served between 30 and 40 degrees. Dietary Staff 1, on 6/1/17 at 6:40 a.m., revealed that the cold foods temperature should be 45 degrees per policy. Review of hospital Policy NS D-9, titled, "Safe Food Handling", revised on June 2015, reads on page 5, "Holding and Serving #2 "Cold foods are held and served at or below 41 degrees F. Those that are potentially hazardous are served at 40 degrees F."

Based on observations, interviews, and review of the hospital policy and procedures, the hospital failed to maintain the building appropriately by not maintaining sidewalks, painted drainage pipes, and wooden ramps.


The findings are:


On 5/30/17 at 1:00 p.m., during a random observations of the hospital, outside of the engineering area of the building, the walkway had gravel and sand from recent flooding. On 6/1/17 at 3:12 p.m., the findings were verified with the Plant Manager. On 5/30/17 at 1:55 p.m., during a random observations of the hospital, outside on the patient patio, peeling paint was observed on metal pipes in 3 areas. On 6/1/17 at 3:13 p.m., the findings were verified with Plant Manager.
On 5/30/17 at 1:58 p.m., during a random observation of the hospital, outside on the patient patio, rotten wood was observed on a wooden ramp used for patient therapy. On 6/1/17 at 3:15 p.m., the findings were verified with the Plant Manager.
Safety Management Plan policy and procedure, reads, "...The Safety Management Plan includes components to maintain and supervise the hospital and all grounds and equipment...".

Based on observations, interview, and review of the hospital's policy and procedure, the hospital failed to ensure 1 of 1 Registered Nurses (RN 5), 1 of 1 Licensed Practical Nurses (LPN 1), 1 of 1 Clinical Certified Hemodialysis Technicians (CCHT 1), 1 of 1 Registered Respiratory Therapist (RRT 1), 2 of 3 Rehab Nurse Technicians (RNT 1 and 2), and 2 of 2 Dietary Staff observed during the provision of care and services failed to follow accepted principles of infection control to prevent the potential cross contamination of infectious agents in the hospital setting.


The findings are:


On 5/30/17 at 2:00 p.m., observations in the Acute Dialysis Unit revealed Rehab Nurse Technician (RNT) 2 failed to perform hand hygiene when exiting the dialysis unit. On 5/30/17 from 2:10 to 2:21 p.m., observations in the hospital's Acute Dialysis Unit revealed CCHT 1 failed to change gloves during the initiation of the arterio-venous fistula (avf) on the patient in bay 2. CCHT 1 cleaned the patient's access site with three (3) alcohol wipes, palpated the access, cannulated the arterial and venous needle, and then adjusted the dialysis machine settings wearing the same pair of gloves. On 5/30/17 at 2:45, CCHT 1 verified the findings, and stated,"I should have changed my gloves after I cleaned her arm." On 5/30/17 at 3:02 and 3:15 p.m., observations in the Acute Dialysis Unit revealed Licensed Practical Nurse 1 assessed the patient in bay 2, and then administered an oral medication to the patient without performing hand hygiene and without donning personal protective equipment (PPE).
On 5/30/17 at 3:35 p.m., observations in the Acute Dialysis Unit revealed RNT 2 and 3 brought a dialysis chair from the previous patient into the dialysis unit and left it in bay 3 without cleaning the chair. On 5/30/17 at 3:47 p.m., RN 2 revealed, "All staff should be wearing PPE when delivering direct patient care."




27380

Observations in Patient 13's room on 05/31/17 at 12:54 a.m. revealed Rehab Nursing Technician (RNT) 1 entered the patient's room to obtain the patient's vital signs. RNT 1 covered the thermometer with a probe cover to take Patient 13's temperature. Once the temperature was taken, RNT 1 ejected the probe cover onto Patient 13's completed lunch plate. RNT 1 left Patient 13's room and moved the vital signs cart to another room without sanitizing the cart. In an interview on 05/31/17 at 4:20 p.m., the hospital Quality Coordinator confirmed the thermometer probe cover should not have been discarded onto Patient 13's lunch plate, and the vital signs cart should have been sanitized before being moved into another patient's room.



29654

During the initial tour of the kitchen on 5/30/17 at 1:20 p.m., observations showed the sink closest to the door was blocked with lunch carts making the hand washing sink inaccessible. Observations showed Dietary Staff 1 walked across the kitchen to another sink that was on the opposite side of the kitchen. Upon entering the kitchen, Dietary Staff 1 was observed donning a hair protector, but did not wash hands while at the accessible sink. Dietary Staff 1 accompanied the surveyor on the tour of the kitchen without washing hands. Dietary Staff 1 revealed, in an interview on 5/31/17 that hands were not washed because he/she was not going to come in direct contact with any food Observations in the kitchen on 6/1/17 at 9:10 a.m. revealed a random dietary staff member entered the kitchen from the hall and did not wash his/her hands upon entering the kitchen. The dietary staff member was observed to be wearing a hair protector. On 5/31/17 at 4:31 p.m., Dietary Staff 18 verified that upon entering the kitchen, all personnel should wear hair covering and wash hands. During an interview with Staff 19 on 6/1/17 at 9:15 a.m., Dietary Staff 19 revealed staff should always wash hands each time they enter the kitchen from an area outside the kitchen. Dietary Management failed to ensure that hand washing procedures were followed by employees entering the kitchen.

Review of hospital policy, titled, "NS D-9 Safe Food Handling", revised June 2015, reads in the Employees Practices section on page 4, "Employees should always wash their hands after coming on duty or taking breaks, touching unclean equipment or work surfaces.....".




36397

On 5/30/17 at 1:55 p.m., random observations during a respiratory treatment with Inpatient 1 revealed the Respiratory Therapist (RRT) 1 entered the patient's room (258 Bed A), performed the assessment of the patient's lungs and oxygen saturation level prior to the patient's respiratory treatment, reassessed the patient's oxygen saturation level after the respiratory treatment, removed the nebulizer from patient's face, and returned it to clean to proper placement. RRT 1 cleaned each piece of equipment used, but failed to disinfect the inside of the oxygen saturation monitor. On 5/30/17 at 2:26 p.m., RRT 1 verified the findings."

On 5/30/17 at 1:30 p.m., random observations during a tour of the Radiology Procedure room revealed Nutrigrain soft baked 1.3 oz (ounce) bars, 1 large bag filled with individual honeygrams crackers .45 oz, and Zesta saltine crackers on the same shelf next to the medications: E-Z Disk 700 mg (milligram) bottles. On 5/30/17 at 1:39 p.m., the Director of Rehabilitation 1 verified the findings.




38774

On 06/01/17 at 8:40 a.m., observations of RN 5 revealed the RN did not clean the medication cart between patient use in that the RN transported the medication from one patient room to another patient room without cleaning the cart. On 06/01/17 at 8:40 a.m., observations of RN 5 revealed the nurse failed to clean the blood pressure cuff after using it on the patient in Bed B in room 242, and before using the blood pressure cuff on the patient in Bed A in room 242. On 06/01/17 at 9:28 a.m., the findings were verified by RN 5.

Hospital Procedure, titled, "Hand Hygiene", reads, "....Staff members will wash their hands when visibly soiled and/or after contact with patients or the environment....".

Hospital policy, titled, "FMS-CS-IC-II-155-080A, Personal Protective Equipment", reads, "....Personal protective equipment such as a full face shield or mask and protective eyewear with full sideshield, fluid-resistant gowns and gloves will be worn to protect and prevent employees from blood or other potentially infectious materials to pass through or to reach the employee's skin, eyes, mouth, other mucous membranes, or work clothes when performing procedures during which spurting or spattering of blood might occur....Employees shall use personal protective equipment namely the combination of fluid-resistant gown, full face shield or mask and protective eyewear with full sideshield, gloves, in accordance with the type of patient contact expected and anticipated exposure....".

Hospital procedure, titled, "Low Level Disinfectants", reads," "....2. Single use disposable towels impregnated with an approved LLD will be used on non-critical items (B/P cuffs, bladder scan machines, electronic thermometer equipment, IV and feeding pumps, pulse oximeters, Work Stations on Wheels, glucometer, laptops, ect....All wipes will contain proper signage in rooms to notify employees, patients and families of proper usage and risk of improper use related to towelettes. 3. All items will be wiped prior to and after patient use....".

Based on personnel record reviews and interview, the hospital failed to ensure the Respiratory Director had the capabilities to supervise and administer the service properly with the authority and delegated/appointed responsibility to oversee the operations within the respiratory department.


The findings are:


On 5/30/17 at 1:41 p.m., the Director of Quality and Risk Management 1 revealed Hospitalist 1 oversees the respiratory department. The surveyor requested to review the appointment for this position. On 5/30/17 at 3:33 p.m., after the second request to review the appointment for the Director of Respiratory Services, the Director of Quality and Risk Management 1 verified there was no documentation of an appointment because Hospitalist 1 was just recently granted the position and the appointment had not gone through the Medical Executive Committee. There was no documentation of the appointment of the previous Medical Director for respiratory services.