The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

PUSHMATAHA HOSPITAL 510 EAST MAIN STREET ANTLERS, OK 74523 July 19, 2016
VIOLATION: GOVERNING BODY Tag No: A0043
Based on observation, document review, and staff interview, it was determined the hospital's governing body failed to ensure the correction of all life safety code citations from the September 2013 CMS recertification survey to include:


K-0062 sprinkler system annual inspections

K-0067 test and balance

K-0078 smoke evacuation inspection and testing

K-0144 generator inspection


In addition to these findings, life safety code deficiencies were also found for annual inspections of equipment and periodic maintenance, line isolation monitors and the medical gas system.


As a result of these deficient practices, the hospital was found to be in immediate jeopardy non-compliance for:

482.12 Condition of Participation: Governing Body,

482.41 Condition of Participation: Physical Environment, and

482.13 Condition of Participation: Patient's Rights. See also Life Safety Code survey.


The governing body also failed to:


a. grant privileges to the radiology physicians who provided telemedicine services and failed to evaluate those physicians for compliance with the Conditions of Participation for Radiology Services and Quality Assessment and Performance Improvement. See tag A-0052;


b. ensure the chief executive officer was responsible for the management of the entire hospital. See tag A-0057;


c. evaluate all contracted services for compliance with the applicable Conditions of Participation and failed to respond to information provided through the hospital's QAPI program that services provided directly by the hospital were not provided according to the applicable conditions of participation. See tag A-0083; and


d. the governing body also failed to ensure the hospital remained in compliance with the Conditions of Participation for 482.23 Nursing Services, 482.26 Radiologic Services, 482.27 Laboratory Services and 482.42 Infection Control.


e. The hospital was asked to provide Board of Trustee meeting minutes for 2015 and 2016. The meeting minutes referred to documents that were not attached to the minutes and although requested, these documents were not provided to the surveyors.
VIOLATION: MEDICAL STAFF Tag No: A0052
Based on document review and staff interview, it was determined the governing body failed to grant privileges to the physicians who provided telemedicine radiology services and failed to evaluate these services as a part of the quality assessment and performance improvement (QAPI) program.

Findings:

On 07/12/0216, the chief operating officer was asked if the hospital provided any telemedicine services. He stated they did not. During the course of the survey, the radiology manager stated radiology studies were read by telemedicine radiologists. A review of patient records confirmed the radiology reports were generated by these physicians.


On 07/14/2016, the COO was asked to provide documentation the telemedicine physicians were granted privileges by the governing body. This information was not provided. The COO provided a list of names from the company that provided the radiology services. One person on the list was identified by one name only. None of the names on the list had documentation of the person's credentials, such as MD or DO. The document did not identify dates of credentialing and did not document the approval of those persons by a governing body. The document had no information about the types of procedures the persons were credentialed to perform.

The document was signed by the Pushmataha Hospital's chief executive officer on 05/06/2016.

On 07/19/2016, the staff person in charge of the medical staff credentialing files stated the hospital did not have any privilege and credentialing information for the telemedicine radiologists.

A review of the QAPI program meeting minutes for 2015-2016 indicated the quality of patient services provided by the telemedicine physicians was not a part of the hospital's QAPI program.

On 07/19/2016, the COO stated the hospital did not evaluate contracted services for quality and for compliance with the applicable Conditions of Participation.
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, document review and staff interview, it was determined the governing body failed to ensure the chief executive officer managed the entire hospital in order to maintain compliance with the Conditions of Participation.

Findings:

1. On 07/12/2016, at 2:20 p.m., the chief operating officer was notified the surveyors would conduct an entrance conference and that he could notify and include any persons he determined necessary. The CEO and the chief nursing officer did not attend the entrance conference.

At 4:00 p.m., the COO stated the hospital shared many services and staff with another hospital located in another town. He was asked to specify what was shared between the two hospitals. He stated Pushmataha Hospital and the other hospital shared the following leadership, hospital services and staff:

Chief Executive Officer

Chief Financial Officer

Chief Nursing Officer

Compliance Officer / QAPI / Risk Management (no other staff assigned to those duties)
Infection Control Professional RN (no other staff assigned to those duties)

Surgery staff

Nursing staff

Radiology Manager and technicians
Laboratory staff

Swing Bed Coordinator

Human Resources Manager

Plant Maintenance Manager and staff

Materiels Management and staff

Medical Records Manager and staff

IT and staff

Patient Registration staff


The COO stated, the hospital did not have an RN appointed as the Director of Nursing solely dedicated to the Pushmataha Hospital. He stated, the hospital had a "site manager" RN who supervised the nursing staff Monday through Friday during business hours. All questions related to nursing services were directed to the RN site manager during the survey. The person identified as the shared chief nursing officer was not present at the hospital at any time during the survey.


The COO also stated the hospital did not have a laboratory manager. He stated the position was vacated two months prior to the survey. He stated the hospital had contracted with a laboratory consultant the day before the survey to help with the management of the lab.



2. The COO was asked to provide the hospital's organizational structure. At 4:30 p.m., the COO provided the name of the chief executive officer. The COO stated, the CEO was not located on the hospital's campus, but had an office at a hospital in another town and that he was the CEO for both hospitals. The COO verified the other hospital was separately licensed and was not a part of a health system that included the Pushmataha Hospital.


On 07/13/2016, the COO was asked to provide the organizational chart for the hospital and the various departments. An organizational chart dated 2015/2016, documented the COO was responsible for radiology, dietary and housekeeping. The chart documented the CEO was responsible for all services. However, marketing, laboratory, physical therapy, pharmacy services, IT, plant maintenance and infection control reported directly to the CEO. Nursing services was not represented on the chart.


The COO was asked to provide the organizational chart that included nursing services. He provided an organizational chart dated 2015/2016, that documented a director of nursing (DON) who was no longer employed by the hospital. This chart documented the DON reported directly to the CEO.


When it was brought to the attention of the COO that the organizational chart was not current, he provided one dated April 01, 2016 - March 31, 2017 that documented the Pushmataha site manager RN reported directly to the CEO. There was no DON or chief nursing officer identified on the chart.


QAPI and safety committee meeting minutes had no documentation a DON or chief nursing officer attended the meetings.


3. The COO was also asked to provide the documentation of the appointment of medical directors for the various clinical departments. He provided a document titled, "Pushmataha Hospital Medical Staff Consultant/Department Directory." The document was not dated and was not signed as approved by the persons who were required to approve it. The form indicated it was to be signed and dated as approved by the chief of staff and two other physicians, a representative of the Board of Trustees, the CEO and the COO.


A review of the medical staff files had no documentation to show the physicians identified on the document as departmental "medical staff consultants" had been formally appointed as clinical medical directors for the various departments.


4. During the course of the survey, quality assessment and performance improvement (QAPI)meeting minutes and reports for 2015 and 2016 were reviewed. The minutes included documentation the CEO was in attendance at the QAPI meetings. The meeting minutes documented ongoing problems with hospital plant maintenance.


QAPI meeting minutes dated 02/10/2016, documented, "... Bio-Med out of compliance..."


QAPI meeting minutes dated 03/09/2016, documented, "... HMS needs to get paid to get caught up on PMs for Nov [2015]... and for Jan & [DATE]... Bio-med out of compliance..."


A Plant Maintenance QAPI committee report, dated 2015 - 2016, documented, "... March [2016] Emergency lights are still pending purchase by [accounts payable] for vendor account is on hold..."


QAPI meeting minutes dated 04/13/2016, documented, "... Bio-med out of compliance..."


A plant maintenance QAPI committee report dated 2016 - 2017, documented, "... April [2016] Emergency light and smoke detectors have been submitted... May [2016] Emergency Light and smoke detectors have been submitted months ago for replacements..."


QAPI meeting minutes dated 05/11/2016, documented, "... Continue to need parts to fix several pieces of equipment... Continue to need PMs done on some equipment... Line isolation and air exchange are due... microscopes in lab to be checked... air exchange due... isolation monitoring for surgery, ER... & med. surg are due... look into [company name deleted] to do generator, fire system, sprinkler system, kitchen hood, air purity & sterilizers yearly checks... Surgery... the fan motor is still out on the blanket warmer. Maintenance has requested a part to be ordered... Continue with issues on PMs getting performed in a timely manner. Radiology reports that we are only 33% compliant with PMs and [our] radiation badges are out of compliance for several months now... Still continue to have an issue with getting the part for the Surgery Blanket Warmer (been needing a part for several months now. Administration is aware of these issues... Our CBC machine has been out half of the month and we have been taking our CBCs to [local physician clinic and out of town hospital name deleted]... Bio-med out of compliance on PMs..."


5. The QAPI meeting minutes included reports from the laboratory regarding issues with lab equipment.


A laboratory department QAPI committee summary report dated 2016 as a review of the year 2015, documented, "... Jan [2015] TAT [turn around time] adversely affected by instrument problems and performing all manual [differentials] on all CBC [complete blood count]..."


"... Mar [2015] TAT adversely affected by CBC instrument obsolete with no service contract and having to do manual differentials..."


"... Oct [2015] TAT adversely affected due to CBC instrument out of contract and having to do 100% manual diffs [differentials]..."


6. A radiology department QAPI report dated 2016, documented, "... PMs are not up to date... payment will need to be made before PMs can be done... PMs are scheduled to be completed once payment is made..."


A radiology department QAPI quarterly report, dated April 12, 2016, documented, "... Radiation badges have been on hold with [vendor name deleted] for this quarter. They will not release them until our balance is paid..."


7. Reports of plant maintenance issues were also provided for the hospital's safety committee. The hospital staff provided documentation the CEO also attended this meeting.


Safety committee meeting minutes dated 03/09/2016, documented, "... 3 smoke detectors to clear fire panel... pending purchase simplex... Preventive Maintenance is not being done as per their schedule. Credit hold since November, Jan./Feb. past due PMs 24 items, 11 are due in March... Surgery needs a new defibrillator... pending approval... Pending no new status or answers for a year now... Refer to the maintenance log and CEO Board report which includes general maintenance and [life safety code] issues that are encountered daily..."


A safety committee report dated 04/13/2016, documented, "... Preventive Maintenance is not being done as per their schedule. On credit hold since November, Jan/Feb past due PMs 24 items, 11 are now due in March, [none scheduled] for April [2016]..."


A hospital document titled, "Plant Vendor Inspections 2016 Update for QAPI/Safety," and dated 05/11/2016, documented, "... Generator annual inspection scheduled for [April] still pending check from [accounts payable]... Annual fire panel & sprinkler system inspection... submitted on 02/22/2016 pending approval... This is all due in March 2016... Inspections due March & April... Airgas annual purity check... Line isolation inspection due in March 2016... [Test and Balance] air exchanges due in April 2016... nine rooms to be done... Contracted vendors that contacted me that have not been paid...[four names deleted]..."


A document dated 06/08/2016, and titled, "Plant Vendor Inspections 2016 Update for QAPI/Safety," documented, "... Generator annual inspection scheduled for [April] still pending check from [accounts payable]... Annual fire panel &s sprinkler system inspection... submitted on 02/22/16 was signed on 05/11/16... This is all due March 2016 and will cover fire panel, sprinkler, fire bottles and kitchen hood...


... Annual inspections due in March & April submitted pending approval... airgas annual purity check... line isolation inspection due March 2016... last year's inspection was not paid and is now due... [test and balance] due in April 2016... 9 rooms to be done... Contracted vendors that contacted me that have not been paid for last year's service... line isolation... annual inspection completed last year on the fire panel and sprinkler system is still pending payment... Plumbing last payment was [May 2015] $700.00 outstanding is $855.00... Submitted quote to fix this issue back on 01/16/15..."


8. The plant maintenance staff provided documentation of reports provided to the CEO regarding the condition of the hospital facilities and patient care equipment.


A hospital document titled, "Plant Maintenance CEO Monthly Report 2016," documented, "... Safety: Annual inspections that were needed for March 2016 and are out of compliance as of this report in April [2016]: 1. Fire Panel inspection 2. Fire Sprinkler 3. Fire Extinguisher 4. Kitchen Hood 5. Airgas [oxygen] purity check 6. Generator load bank 7. Test and Balance 8. OR/Scope [room] Line Isolation Monitors. Plant is currently pending approval response from administration on all the [items] listed above. Some of the vendors are in need of payment for last year's services rendered and are now [cash on delivery]..."


A hospital document titled, "Plant Maintenance CEO Monthly Report 2016 April and May," documented, "... The month of April's work log consisted of 201.5 hours barely 1 FTE. [Name deleted] worked only 12 days for this month... our life safety monitoring we have needed emergency lighting to be replaced or bought months ago... Upper management's decision to downsize and cut staff maintenance for this location, due to money constraints and or funding has added a huge workload. I'm only able to do reactive maintenance instead of the proactive kind that's needed. The plant equipment and facility will not last long doing this kind of maintenance... As mentioned in previous months, we still need smoke detectors purchased to fix our fire panel troubles...


... [Name deleted] has given a quote on 02/22/16 to do all our [life safety code] here at Push, I've submitted and forwarded to Push COO to get approval and also started working on getting them to quote smoke detectors... I have also submitted a request for purchase of some emergency lights to be replaced, since batteries will not charge. Submitted a second time for approval back in 06/25/15 and are still pending PO [purchase order] response. As I have reported before room 110 and now new rooms 106, 108 needs new patient station [nurse emergency call system] to be purchased... Surgery suite blanket warmer services on 11/17/15 and I found axial fan is out; a replacement has been located and was submitted for purchase. Autoclave pop off was submitted for replacement on 08/31/15. As mentioned previously, a Hit List of items has been prepared and submitted on 11/17/15 to COO to get those necessary repair items...


... The month of May's work log consisted of 110.25 hours for a no FTE. The emergency lighting is still out and need replacements... quotes have been submitted long ago multiple times and the 4 smoke detectors have been mentioned in April's safety [report] above and in the last 9 months of this report. As mentioned in March report during a team meeting I turned in after QAPI/Safety meeting, a list of most, but not all of our needed parts and supplies to be purchased so we can continue to stay in state compliance. These parts will help with equipment PMs and for some safety issue repairs... Yesterday I contacted our gas supplier (Airgas)... the manager stated they are about to come pickup all our bottles for both locations and close the accounts due to non-payment. He also mentioned that the Finance department was contacted multiple times and no one will return his calls... [Hospital name deleted] COO was notified immediately at 11:55 on 06/01/16..."


During the course of the survey observations, the staff verified the items listed in the document above were still out of compliance. The staff stated hospital's CEO had not provided the funds for this work to be done.


9. A hospital document dated 06/08/2016, and titled, "Pushmataha Hospital Compliance Board Report," documented, "... Lab - ER stat turnaround time for the month of May was unable to obtain [due to] machines down and no reagents at times... CBC machine went down in May and we continue to carry labs to [local physician clinic and out of town hospital names deleted]... Blanket warmer issues in surgery from November to present continues to be out of service. Mechanical parts have been requested and received at this time..."


10. During tours of the various departments of the hospital, the staff were asked about unrepaired equipment, lack of supplies, household cleaning products used for disinfection and the lack of linen inventory and failure to supply hospital-grade anti-bacterial hand soaps. The staff stated the CEO would not release funds for these items and either the COO would purchase items at the local grocery stores or staff would bring in their own supplies for use.


There were observations of the re-use of single patient use items. The staff used torn and damaged items because they had no substitutions. The staff reported that biohazardous waste was collected and stored in an outbuilding for several months because the contracted vendor had not been paid and no longer would come to the hospital to remove the waste.


The stationary radiology exam equipment had been removed from the radiology department. Wires were left exposed in the ceiling. The staff did not know why the equipment was removed but they said they were promised that a down-payment had been made on replacement equipment. For several months the hospital had only been able to provide limited portable x-rays and CT scans.


Staff in the dietary department stated the vendor for food delivery had not been paid and the staff would go to the grocery stores and buy patient food. They stated they were unable to follow the dietitian's menu plan or provide adequate substitutions.


The dietary staff had asked if the auxillary volunteers could purchase a cart to keep patient food covered and warm for delivery to the patient unit.


Multiple committee meeting minutes documented the lack of adequate funds to run hospital departments.


11. On 07/18/2016, at 2:50 p.m., the chief operating officer was notified the hospital was in immediate jeopardy non-compliance related to life safety code, physical environment, patient's rights and governing body. He was offered the opportunity to include the CEO or any other manager in the meeting to discuss the specifics of the immediate jeopardy. The COO asked the manager of plant maintenance to attend. The CEO did not attend.


12. On 07/19/2016, at 1:30 p.m., the COO was notified the survey team was preparing to hold an exit conference and he could include at that meeting, any staff of his choosing. The CEO and the DON did not attend the exit conference.
VIOLATION: CONTRACTED SERVICES Tag No: A0083
Based on document review and staff interview, it was determined the hospital failed to evaluate contracted services for compliance with the Conditions of Participation.


Findings:


On 07/13/2016, the hospital's chief operating officer provided a list of contracted services for the hospital. Hospital quality assessment and performance improvement meeting minutes were reviewed for 2015 and 2016. There was no documentation those contracted services were evaluated for compliance with the applicable Conditions of Participation.


The COO verified the hospital did not evaluate those services.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on hospital document review, staff interview and observation, it was determined immediate jeopardy existed in the Condition of Participation of Physical environment when the facility failed to:


a) ensure it was arranged, constructed and maintained to ensure the safety of all patients served; (See Life Safety Code K tags)


b) ensure all patient care equipment had current preventative maintenance and testing; (See tag A-0701 and Life Safety Code K tags)


c) ensure life safety from fire requirements were met; (See Life Safety Code K tags)


d) ensure fire extinguishers were tested and maintained annually; (See tag A-0715)


e) maintain adequate facilities for all services provided. (See tag A-0722)


f) ensure battery powered back-up emergency lighting was inspected and maintained (See tag A-0711)


g) maintain proper ventilation in the Operating Room and Emergency Department soiled utility room (See Life Safety Code K-0067)
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on hospital document review, staff interview, and observation, it was determined immediate jeopardy conditions existed in the Condition of Participation of Patient Rights when the facility failed to provide patients care in a safe physical environment and failed to notify patients of no physician availability 24 hours a day 7 days a week.


Findings:

a) ensure it was arranged, constructed and maintained to ensure the safety of all patients served; (See Life Safety Code K tags 22, 25, 27, 29, 39, 46, 52, 54, 62, 64, 67, 69, 76, 141, 144, 147, and 211)


b) ensure all patient care equipment had current preventative maintenance and testing; (See tag A-0701 and Life Safety Code K tags 46, 52, 54, 62, 64, 67, 211)


c) ensure life safety from fire requirements were met; (See Life Safety Code K tags 22, 25, 27, 39, 52, 54,62, 64,69)


d) ensure fire extinguishers were tested and maintained annually; (See tag A-0715)


e) maintain adequate facilities for all services provided. (See tag A-0722)


f) ensure battery powered back-up emergency lighting was inspected and maintained (See tag A-0711, K Tags 46, 144)


g) maintain proper ventilation in the Operating Room and Emergency Department soiled utility room (See Life Safety Code K-0067)



The accumulated effect of these deficient practices failed to ensure the safety and well-being of patients.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on hospital document review and staff interview, the facility failed to notify all patients of no physician availability 24 hours per day 7 days per week.


Findings:


1. On 07/14/2016, at 10:33 a.m., surveyors reviewed a patient admission packet provided by the hospital. Staff XX told surveyors the admission packet reviewed was the current admission packet given to all patients. The admission packet did not document there was no physician availability 24 hours per day 7 days per week.


2. On 07/14/2016 at 11:44 a.m., Staff D told surveyors the hospital did not provide the patients with notification of no physician availability 24 hours per day 7 days per week.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, interviews, and documentation, the hospital failed to provided an organized nursing service under the supervision of a Director of Nursing.


Findings:


The hospital failed to clearly designate a Director of Nursing who was responsible for nursing personnel and staff that provide nursing care services. See Tag A-0386
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Findings:


On 07/12/2016, at 4:00 p.m., the COO stated the hospital shared many services and staff with another hospital located in another town. He was asked to specify what was shared between the two hospitals. He stated Pushmataha Hospital and the other hospital shared the following leadership, hospital services and staff including Chief Nursing Officer.


The COO stated, the hospital did not have an RN appointed as the Director of Nursing solely dedicated to the Pushmataha Hospital. He stated, the hospital had a "site manager" RN who supervised the nursing staff Monday through Friday during business hours. All questions related to nursing services were directed to the RN site manager during the survey. The person identified as the shared chief nursing officer was not present at the hospital at any time during the survey.



~On 07/13/2016, both the Chief Operating Officer and the Site Manager (Staff D) told surveyors the DON was Staff A. The surveyor's requested the personnel file for Staff A. No personnel file for Staff A was provided.


~Surveyors reviewed a document titled, "Pushmataha Employee 07/12/16." Staff A was listed as an "RN" not the DON. Multiple staff in various departments told the surveyors they rarely saw Staff A in the facility. During the 6 day course of the survey, Staff A was not present on site.


~The surveyors requested the hospital's most current organizational chart. Multiple versions of the organizational chart were provided.


~One organizational chart titled, "Plan for Provision of Patient Care Services 04/01/2015 -03/31/2017," documented Staff AAA as the DON. Staff told surveyors that Staff AAA no longer worked at the hospital and has been gone since October 2015. This organizational chart did not document a position for a Site Manager.


~Another organizational chart provided to the surveyors, titled, "Plan for Provision of Patient Care Services 04/10/2016 - 03/31/2017," did not document a DON position. This organization chart documented a position for a site manager. Staff D was listed as the site manager with initials above Staff D's name. The initials above staff D's name were for Staff A.


~Multiple staff from various departments told surveyors, Staff D, the site manager was their main contact for all staffing issues, patient care issues, and clinical operational matters.


~Surveyors requested and reviewed the personnel file for Staff D. The personnel file for Staff D contained personnel paperwork that documented various nursing positions for staff D, such as, Site Manger, Director of Nursing, and Interim Chief Nursing Officer. The signed job description in Staff D's personnel file was titled Site Manager, not DON.


~Surveyors requested and reviewed job descriptions for hospital staff. A binder, titled, "Job Descriptions" was provided. The binder contained a job description for the DON but not a job description for Site Manager.


~Surveyors reviewed Quality meeting minutes from 2015 -2016. The quality meeting minutes contained a staff signature page for those staff in attendance. Staff D, the site manager had signed attendance for multiple meetings. Staff A and Staff AAA who were both identified as the DON on the organizational charts provided and by staff interview had not signed attendance pages in any meeting minutes reviewed.
VIOLATION: UNUSABLE DRUGS NOT USED Tag No: A0505
Based on observation, staff interviews, and document review, the hospital failed to remove outdated drugs/ biologicals from the patient care area.


Findings:


On 07/13/2016, during the facility tour, 11 outdated medications were found in the crash cart and airway box within the emergency room - Trauma 1 Room. Staff P stated Trauma 1 Room was the primary room used for the incoming critically ill patient. Staff P stated it was the pharmacist's responsibility to check the crash cart for medication expirations.


The hospital document titled, "June 2016 Monthly/Weekly Floor Stock Checks", documented the crash cart in Trauma 1 as meeting criteria. July 2016 checks were not provided.


Also, outdated intravenous (IV) bags of saline solution were ready for patient use within the CT Room in the Radiology Department. The saline bags expired in 2014. Expired medication was found in the Operating Room.


The pharmacist stated she had delegated the maintenance responsibility of all hospital departments' medication to the drug room supervisor. The drug room supervisor was responsible for validating all medication was within the manufacturer's date for use and handling/stored according to hospital pharmaceutical policies and procedures.
VIOLATION: RADIOLOGIC SERVICES Tag No: A0528
Based on hospital document review and staff interview, the facility failed to:


a) ensure a medical director was appointed over the Radiology Department; (See tag A-0539)


b) failed to ensure physicians who provided radiological services were granted privileges by the Governing Body; (See tag A-0539)


c) ensure all Radiology staff were monitored for radiation exposure. (See tag A-0538)
VIOLATION: MONITORING RADIATION EXPOSURE Tag No: A0538
Based on hospital document review and staff interview, the facility failed to ensure all Radiology staff were monitored for radiation exposure.


Findings:


~ On the of July 14, 2016, the Radiology Director told surveyors the radiology staff had not had radiation monitoring devices since November, 2015.


A policy, titled, "Radiation Safety-Patient and Employee," documented "...a radiation monitoring device shall be worn by Imaging Services personnel at all times while on duty and will be checked routinely once every three months..."


A document, titled, "Occupational Dose Record for a Monitoring Period," documented dosimetry monitoring dates of 09/10/2015 - 11/09/2015.


A radiology department Quality Assessment Performance Improvement (QAPI) report, dated April 12, 2016, documented "...Radiation badges have been on hold with [vendor name deleted] for this quarter. They will not release them until our balance is paid..."
VIOLATION: MEDICAL ORDERS FOR RADIOLOGY SERVICES Tag No: A0539
Based on hospital document review and staff interview, the facility failed to ensue radiological services were provided only by credentialed practitioners who were granted privileges by the Governing Body.


Findings:


During the course of the survey, the radiology manager told surveyors Staff YY was the medical director of radiology and radiology studies were read by telemedicine radiologists. A review of patient records confirmed the radiology reports were generated by these physicians.


During the course of the survey, surveyors requested the credentialing file for Staff YY. No credentialing file was provided.


On 07/14/2016, the COO was asked to provide documentation the telemedicine physicians were granted privileges by the governing body. This information was not provided. The COO provided a list of names from the company that provided the radiology services. One person on the list was identified by one name only. None of the names on the list had documentation of the person's credentials, such as MD or DO. The document did not identify dates of credentialing and did not document the approval of those persons by a governing body. The document had no information about the types of procedures the persons were credentialed to perform.


The document was signed by the Pushmataha Hospital's chief executive officer on 05/06/2016.


On 07/19/2016, the staff person in charge of the medical staff credentialing files stated the hospital did not have any privilege and credentialing information for the telemedicine radiologists.


A review of the QAPI program meeting minutes for 2015-2016 indicated the quality of patient services provided by the telemedicine physicians was not a part of the hospital's QAPI program.
VIOLATION: LABORATORY SERVICES Tag No: A0576
Based on hospital document review and staff interview, the facility failed to:


a) ensure adequate laboratory services were available to meet the needs of the patients;


b) ensure a physician medical director was appointed as the laboratory medical director;



Findings:


On 07/12/2016, at 4:00 p.m., the COO stated the hospital shared many services and staff with another hospital located in another town. He was asked to specify what was shared between the two hospitals. He stated Pushmataha Hospital and the other hospital shared the following leadership, hospital services and staff including Laboratory staff.


The COO also stated the hospital did not have a laboratory manager. He stated the position was vacated two months prior to the survey. He stated the hospital had contracted with a laboratory consultant the day before the survey to help with the management of the lab.


A laboratory department QAPI committee summary report dated 2016 as a review of the year 2015, documented, "... Jan [2015] TAT [turn around time] adversely affected by instrument problems and performing all manual [differentials] on all CBC [complete blood count]..."


"... Mar [2015] TAT adversely affected by CBC instrument obsolete with no service contract and having to do manual differentials..."


"... Oct [2015] TAT adversely affected due to CBC instrument out of contract and having to do 100% manual diffs [differentials]..."




~ On the afternoon of July 12, 2016, surveyors toured the laboratory department. There were multiple blood collection tubes expired. There were multiple laboratory reagents expired. (reagents are used to detect or synthesize another substance in a chemical reaction). Expired reagents may not provide a reliable test.


~ During the course of the survey, the Chief Operating Officer (COO) told surveyors there was not a physician medical director appointed over the laboratory. The COO could not provide information as to how long the laboratory had been without a physician medical director.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on preventative maintenance document review, Quality Assessment Performance Improvement (QAPI) meeting minutes review, staff interview, and observation, the facility failed to ensure the condition of the physical plant and hospital environment were maintained to ensure the safety of patients, and failed to ensure all patient care equipment had current preventative maintenance and testing.


Findings:


1. See deficient practices cited under the Life Safety Code K-tags


2. On the afternoon of 07/12/2016, and morning of 07/13/2016, the surveyors toured all departments of the hospital.


3. During the tour, surveyors observed multiple patient care equipment to include life saving equipment with stickers of preventative maintenance dated as expired at the time of the survey. Equipment that is not inspected by manufacturer's guidelines poses an increased risk for patient and/or staff injury.


~ Two Intravenous(IV) infusion pumps on the patient care unit dated preventative maintenance (PM) due 11/15

~ IV pump on the patient care unit dated PM due 02/16

~ Defibrillator on the patient care unit dated PM due 11/15

~ Datascope (a machine used to monitor patient vital signs) in the Endoscopy suite dated PM due 07/15

~ Monitor screen in the Endoscopy suite dated PM due 05/16

~ Cautery machine in the Endoscopy suite dated PM due 11/15

~ Portable suction machine in the Operating Room (OR) corridor dated PM due 5/16

~ Exam lamp in an equipment storage room dated PM due 8/15

~ Tourniquet system in an equipment storage room dated PM due 5/16

~ Stryker tower used for laparoscopic surgeries in an equipment storage room dated PM due 5/16

~ Cautery machine in the OR dated PM due 11/15

~ Bair hugger machine in the OR dated PM due 3/16

~ Anesthesia machine in the OR dated PM due 3/15

~ Defibrillator in the OR corridor dated PM due 4/15

~ Sterilizer in the OR department dated last PM was in 2013, Staff Q told surveyors the recording needle that recorded the amount of time for sterilizing equipment gets stuck on occasion.

~ Blanket warmer in the OR corridor no dated last PM and warmer was broken.

~ Power injector in Radiology with a blank PM sticker.

~ Ultrasound machine in the Physical Therapy (PT) department dated PM due 01/16

~ Hydrocollator in the PT department dated PM due 01/16


4. QAPI meeting minutes for the last year documented equipment PMs out of date multiple times. QAPI meeting minutes dated March 9, 2016, documented, "...Preventative Maintenance is not being done as per their schedule. Credit hold since November, Jan/Feb past due pm's 24 times..."


5. On 07/19/2016, surveyors reviewed the hospital's preventative maintenance log dated 07/13/2016. The log contained documentation 24 patient care equipment out of 35 patient care equipment listed were out of date for PM. The out of date equipment was scheduled for PMs ranging from 11/2015 - 05/2016.


6. On 07/13/2016, at 4:20 p.m., Staff H told surveyors the Stryker tower in the OR had "gone down" during a surgical procedure in the month of May. Staff H told the surveyor the scope camera kept fogging. Staff H told the surveyor the surgical procedure was cancelled. Staff H told the surveyor the manufacturer (Stryker) brought in a demo tower for the next month and procedures were done. Staff H told the surveyor the Stryker tower had not had a PM done by the hospital's biomedical engineer prior to use. All equipment used at the hospital should have PM checks by the hospital's biomedical engineer before use.
VIOLATION: LIFE SAFETY FROM FIRE Tag No: A0709
Based on hospital document review, staff interview and observation, the facility failed to ensure life safety from fire requirements were met.

Findings:

See Life Safety Code K tags
VIOLATION: REGULAR FIRE AND SAFETY INSPECTIONS Tag No: A0715
Based on observation and record review it was determined the facility failed to ensure fire extinguishers were tested and maintained annually.


Findings:


On 07/12/2016 at 15:20, the annual inspection reports for the facility's fire extinguishers was requested and not provided.
VIOLATION: FACILITIES Tag No: A0722
Based on observation and staff interview, the facility failed to ensure it maintained adequate facilities for all services provided.


Findings:


~ On the afternoon of 07/12/2016, and the morning of 07/13/2016, the surveyors toured all departments of the hospital.


Observations:


Radiology:

~ A room was repurposed into a storage room for acetates.

~ The patient dressing room was repurposed into a storage closet. The dressing room/storage closet contained a broken ceiling exhaust fan and a broken light fixture base.

~ The housekeeping department contained no self-closing hardware.


Emergency Department (ED):


~ Staff lockers were located in the ED patient triage room.

~ There was no provisions for a separate staff locker room.

~ The ED contained no exam/treatment room.

~ The ED contained no security/seclusion room for patient's who would need close psychiatric monitoring/care.

~ The ED contained no secured holding room.



Medical Surgical Patient Care Unit:

~ The medical surgical patient care unit contained no examination/treatment room.

~ The medical surgical patient care unit contained no security seclusion room.

~ The bathroom light in Room 102 on the medical surgical unit did not work.


Laundry room:

~ Staff lockers were located in the clean laundry room.

~ Patient belongings were located in the clean laundry room.

~ A staff "breakroom" was located in the clean laundry room.

~ A microwave was located in the dirty laundry room.

~ The facility was processing linen from another hospital. There was no clear separation of the linen from the facility and the linen from the other facility.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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

a. perform routine and preventive maintenance (PM) on medical equipment and environmental systems and failed to replace critical equipment when necessary;

b. ensure the hospital maintained adequate supplies to meet the needs of the patients; and

c. the hospital failed to store supplies in a manner to prevent contamination.

See also Tag A-0701.


Findings:


a. During tours of the hospital, observations were made of biomedical equipment in all departments that did not have evidence of current preventive maintenance. Various staff members stated the hospital had not paid the contractors who performed preventive maintenance.


The chief operating officer was asked to provide documentation of the hospital's preventive maintenance program, the quality assurance program, safety committee meeting minutes and reports to the chief executive officer and the governing body. The following documents were provided:


Hospital biomedical equipment safety reports documented the following status reports for 2015 and 2016.


November 2015

Thirty-two patient care equipment items for various departments were pending for preventive maintenance. Some items were still pending from 2013, 2014 and 2015 to include equipment in surgery (lights, electrocautery units, and electronic thermometers). The report documented, "... HMS will perform November preventive maintenance when they get paid..."


December 2015

No items were listed on the report. The report documented, "... No HMS preventive maintenance is scheduled for December 2015. HMS is unable to perform preventive maintenance because Pushmataha Hospital is on credit hold."


January 2016

Three items for the physical therapy department were listed on the report. The report documented, "... HMS will perform January preventive maintenance when they get paid..."


February 2016

Twenty-one items for the nursing department and the respiratory therapy department were listed on the report. The report documented, "... HMS will perform February preventive maintenance when they get paid..."


March 2016

Eleven equipment items for nursing services and the surgery department were listed on the report. The report documented, "... HMS will perform March preventive maintenance when they get paid..."


April 2016

No items were listed on the report. The report documented, "... No HMS preventive maintenance is scheduled for April 2016. HMS is unable to perform preventive maintenance because Pushmataha Hospital is on credit hold... HMS informed because Pushmataha Hospital is on a credit hold for past due amount of $14,526.75 as of last week and ... Pushmataha Hospital won't be able to have [vendor name deleted] perform PMs on the ventilators until the past due amount is paid and Pushmataha Hospital continues to pay on time... Services contract must be signed to have sterilizer and scope washer PMs performed and... Pushmataha Hospital would be able to pay in advance to have these PMs performed..."


May 2016

Thiry-six items were listed on the report for various departments, including the following:

Emergency Department - defibrillator and an infant warmer last PM in May 2015 but was required semi-annually and was due in Nov. 2015.

Laboratory - centrifuge PM due Nov. 2015

Nursing department - defibrillator PM due Nov. 2015, patient electric beds last PM performed in May 2014

Surgery - 16 patient care items due (two electro-cautery units past due from Nov. 2015)
The report documented, "... HMS unable to perform preventive maintenance because Pushmataha Hospital is on credit hold..."


June 2016

Twenty items were listed on the report for various departments. The report documented, "... HMS unable to perform preventive maintenance because Pushmataha Hospital is on credit hold..."


A plant maintenance summary report dated 2015 - 2016 documented, "... [January 2015]... All for the most part we are in fair standing even considering the lack of funding for repairs. We have been able to maintain most of the equipment on a reactive type repair in an emergency instead of a proactive approach for PMs and inspections... [March 2015] No change in funding...


A Plant Maintenance report for January, February, and March 2016, documented, "... Emergency lighting needs replaced... we still need smoke detectors... to fix our fire panel troubles that has been ongoing for months now the local fire chief stop and asked me what's going on with it as they are called and notified from our monitoring service... speaking with [name deleted] he said they have a way of getting the smoke detectors for us and will work up a quote for replacement on those and our much needed fire panel batteries... I have also submitted a request for purchase of some emergency lights to be replaced, since batteries will not charge... Submitted for a second time for approval back in 06/25/15 and are still pending..."


A Plant Maintenance QAPI committee report, dated 2015 - 2016, documented, "... March [2016] Emergency lights are still pending purchase by [accounts payable] for vendor account is on hold..."


A hospital document titled, "Plant Maintenance CEO Monthly Report 2016," documented, "... Safety: Annual inspections that were needed for March 2016 and are out of compliance as of this report in April [2016]:

1. Fire Panel inspection

2. Fire Sprinkler

3. Fire Extinguisher

4. Kitchen Hood

5. Airgas [oxygen] purity check

6. Generator load bank

7. Test and Balance

8. OR/Scope [room] Line Isolation Monitors. Plant is currently pending approval response from administration on all the [items] listed above. Some of the vendors are in need of payment for last year's services rendered and are now [cash on delivery]..."


A hospital document titled, "Plant Maintenance CEO Monthly Report 2016 April and May," documented, "... The month of April's work log consisted of 201.5 hours barely 1 FTE. [Name deleted] worked only 12 days for this month... our life safety monitoring we have needed emergency lighting to be replaced or bought months ago... Upper management's decision to downsize and cut staff maintenance for this location, due to money constraints and or funding has added a huge workload. I'm only able to do reactive maintenance instead of the proactive kind that's needed. The plant equipment and facility will not last long doing this kind of maintenance... As mentioned in previous months, we still need smoke detectors purchased to fix our fire panel troubles...


[Name deleted] has given a quote on 02/22/16 to do all our [life safety code] here at Push, I've submitted and forwarded to Push COO to get approval and also started working on getting them to quote smoke detectors... I have also submitted a request for purchase of some emergency lights to be replaced, since batteries will not charge. Submitted a second time for approval back in 06/25/15 and are still pending PO [purchase order] response. As I have reported before room 110 and now new rooms 106, 108 needs new patient station [nurse emergency call system] to be purchased... Surgery suite blanket warmer services on 11/17/15 and I found axial fan is out; a replacement has been located and was submitted for purchase. Autoclave pop off was submitted for replacement on 08/31/15. As mentioned previously, a Hit List of items has been prepared and submitted on 11/17/15 to COO to get those necessary repair items...


The month of May's work log consisted of 110.25 hours for a no FTE. The emergency lighting is still out and need replacements... quotes have been submitted long ago multiple times and the 4 smoke detectors have been mentioned in April's safety [report] above and in the last 9 months of this report. As mentioned in March report during a team meeting I turned in after QAPI/Safety meeting, a list of most, but not all of our needed parts and supplies to be purchased so we can continue to stay in state compliance. These parts will help with equipment PMs and for some safety issue repairs... Yesterday I contacted our gas supplier (Airgas)... the manager stated they are about to come pickup all our bottles for both locations and close the accounts due to non-payment. He also mentioned that the Finance department was contacted multiple times and no one will return his calls... Atoka COO was notified immediately at 11:55 on 06/01/16..."


A plant maintenance QAPI committee report dated 2016 - 2017, documented, '"... April [2016] Emergency light and smoke detectors have been submitted... May [2016] Emergency Light and smoke detectors have been submitted months ago for replacements..."


A hospital document dated 06/08/2016 and titled, "Plant Vendor Inspections 2016 Update for QAPI/Safety," documented, "... Generator annual inspection scheduled for [April] still pending check from [accounts payable]... Annual fire panel &s sprinkler system inspection... submitted on 02/22/16 was signed on 05/11/16... This is all due March 2016 and will cover fire panel, sprinkler, fire bottles and kitchen hood...


... Annual inspections due in March & April submitted pending approval... airgas annual purity check... line isolation inspection due March 2016... last year's inspection was not paid and is now due... [test and balance] due in April 2016... 9 rooms to be done... Contracted vendors that contacted me that have not been paid for last year's service... line isolation... annual inspection completed last year on the fire panel and sprinkler system is still pending payment... Plumbing last payment was [May 2015] $700.00 outstanding is $855.00... Submitted quote to fix this issue back on 01/16/15..."


During the course of the survey observations, the staff verified the items listed in the document above had not been inspected and/or tested and were still out of compliance. The staff stated hospital's CEO had not provided the funds for this work to be done.


A laboratory department QAPI committee report dated 2016, documented, "... Jan [2015] TAT [turn around time] adversely affected by instrument problems and performing all manual [differentials] on all CBC [complete blood count]..."

"... Mar [2015] TAT adversely affected by CBC instrument obsolete with no service contract and having to do manual differentials..."

"... Oct [2015] TAT adversely affected due to CBC instrument out of contract and having to do 100% manual diffs [differentials]..."


A hospital document dated 06/08/2016, and titled, "Pushmataha Hospital Compliance Board Report," documented, "... Lab - ER stat turnaround time for the month of May was unable to obtain [due to] machines down and no reagents at times... CBC machine went down in May and we continue to carry labs to [local physician clinic and out of town hospital names deleted]... Blanket warmer issues in surgery from November to present continues to be out of service. Mechanical parts have been requested and received at this time...


A radiology department QAPI report dated 2016, documented, "... PMs are not up to date... payment will need to be made before PMs can be done... PMs are scheduled to be completed once payment is made..."


Quality Assurance and Performance Improvement (QAPI) meeting minutes dated 02/10/2016, documented, "... Bio-Med out of compliance..."


QAPI meeting minutes dated 03/09/2016, documented, "... HMS needs to get paid to get caught up on PMs for Nov [2015]... and for Jan & [DATE]... Bio-med out of compliance..."


QAPI meeting minutes dated 04/13/2016, documented, "... Bio-med out of compliance..."


QAPI meeting minutes dated 05/11/2016, documented, "... Continue to need parts to fix several pieces of equipment... Continue to need PMs done on some equipment... Line isolation and air exchange are due... microscopes in lab to be checked... air exchange due... isolation monitoring for surgery, ER... & med. surg are due... look into [company name deleted] to do generator, fire system, sprinkler system, kitchen hood, air purity & sterilizers yearly checks... Surgery... the fan motor is still out on the blanket warmer. Maintenance has requested a part to be ordered... Continue with issues on PMs getting performed in a timely manner. Radiology reports that we are only 33% compliant with PMs and [our] radiation badges are out of compliance for several months now... Still continue to have an issue with getting the part for the Surgery Blanket Warmer (been needing a part for several months now. Administration is aware of these issues... Our CBC machine has been out half of the month and we have been taking our CBCs to [local physician clinic and out of town hospital name deleted]... Bio-med out of compliance on PMs..."


Safety committee meeting minutes dated 03/09/2016, documented, "... 3 smoke detectors to clear fire panel... pending purchase simplex... Preventive Maintenance is not being done as per their schedule. Credit hold since November, Jan./Feb. past due PMs 24 items, 11 are due in March... Surgery needs a new defibrillator... pending approval... Pending no new status or answers for a year now... Refer to the maintenance log and CEO Board report which includes general maintenance and [life safety code] issues that are encountered daily..."


A safety committee report dated 04/13/2016, documented, "... Preventive Maintenance is not being done as per their schedule. On credit hold since November, Jan/Feb past due PMs 24 items, 11 are now due in March, [none scheduled] for April [2016]..."


A hospital document titled, "Plant Vendor Inspections 2016 Update for QAPI/Safety," and dated 05/11/2016, documented, "... Generator annual inspection scheduled for [April] still pending check from [accounts payable]... Annual fire panel & sprinkler system inspection... submitted on 02/22/2016 pending approval... This is all due in March 2016... Inspections due March & April... Airgas annual purity check... Line isolation inspection due in March 2016... [Test and Balance] air exchanges due in April 2016... nine rooms to be done... Contracted vendors that contacted me that have not been paid...[four names deleted]..."


b. During the survey, household bath towels in a variety of colors were found on the nursing unit and in the housekeeping department. The staff stated the hospital periodically runs out of linens and a physician had purchased those household towels on a weekend when the hospital had none for the patients.


A housekeeping QAPI committee report dated 2015-2016, documented, "... June [2015] Blankets have been ordered and the status is pending... July [2015] There continues to be a linen shortage. We are short on blankets and flat sheets... August [2015] Blankets, flat sheets and fitted sheets have been ordered and we are currently awaiting arrival... Currently need soap for the room dispensers... January [2016] We have another shortage of linen this month. We are running out of top sheets, blankets and pillows..."


c. During a tour of the hospital's materiel's management department, sterile IV solutions were observed de-cased and stored in their protective packaging on open unfinished wood shelving near the receiving dock garage door. Sterile supplies for the surgery department were also de-cased and stored on open unfinished wood shelving. The staff working in the materiel's department stated those supplies were routinely taken from the materiel's storage shelves directly into the operating rooms. The materiel's staff also stated they had not considered the possible environmental contamination to those products and the transfer of contaminants to the surgery department.
VIOLATION: VENTILATION, LIGHT, TEMPERATURE CONTROLS Tag No: A0726
Based on hospital document review, staff interview and observation, the facility failed to maintain proper ventilation in the Operating Room and the Emergency Department soiled utility room.


Findings:


See Life Safety Code K-0067
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on infection control meeting minutes review, infection control surveillance review, infection control policies and procedures review, staff interview and observation, the facility failed to:

a) provide a safe and sanitary environment to avoid sources of infections and communicable diseases. (See tag A-0749)

b) ensure proper cleaning and disinfecting of patient care equipment. (See tag A-0749)

c) provide appropriate policies and procedures for cleaning and disinfecting patient care equipment. (See tag A-0749)

d) ensure the Chief Executive Officer, Medical Staff and Director of Nursing addressed problems identified and implemented a corrective action plan.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on infection control meeting minutes review, infection control policies and procedures review, infection control surveillance data review, staff interview, and observation, the facility failed to ensure the infection control officer:

a) maintained a sanitary safe environment through active surveillance;

b) ensured proper cleaning and disinfection for patient care equipment;

c) ensured manufacturer guidelines were followed in the cleaning and disinfection of patient care equipment;

d) maintained safe air handling systems in the operating room. (see Life Safety Code K-0067); and

e). the hospital failed to follow its system to monitor employees and medical staff for symptoms of tuberculosis and failed to assess employee and physician immunization status.

Findings:

~ On the morning of 07/12/2016, the surveyors requested all infection control policies and procedures, all infection control surveillance data, and infection control meeting minutes for the past year.

~ Review of infection control meeting minutes contained no documentation of a hospital wide infection control risk assessment. On 07/13/2016, at 4:20 p.m., Staff F told surveyors that she had not done a hospital wide infection control risk assessment.

~ Review of infection control meeting minutes and other infection control documentation did not contain evidence of medical staff and governing board approval of all chemicals and disinfectants used. Staff F provided the surveyors with a list of chemicals and disinfectants currently used but there was no evidence the chemicals and disinfectants were approved.

~ On the afternoon of 07/12/2016, surveyors observed staff D with artificial fingernails. Staff D told surveyors she did provide direct care to patients. On the morning of 07/19/2016, surveyors reviewed a hospital policy, titled, "Artificial Fingernails." The policy documented, "...If a staff member's job includes "hand-on" direct patient care ...artificial nails or artificial nail products, e.g., tips, jewelry, overlays, wraps, etc., may not be worn ... "

~ On the morning of 07/13/2016 nursing staff told surveyors they used a point of care monitor to perform blood glucose checks on patients. Staff R told surveyors alcohol rub was used to clean the monitor. Staff P told surveyors a bleach product was used to clean the monitor. On the afternoon of 07/13/2016, surveyors reviewed a policy titled, "Glucometer Cleaning and Disinfection." The policy documented, "...disinfect glucometers using bleach disinfectant wipes or a dilute bleach solution of 1:10 (one part bleach to 9 parts water.)" The policy further documented, "...alcohol is not effective against all pathogens..."

~ On the afternoon of 07/12/2016, & the morning of 07/13/2016, the surveyors toured all departments of the hospital.

Observations:

Medical Surgical Patient Care Unit:

~ Two patient rooms dedicated as "ready" for patient use contained trash in trash can. A room ready for use should not have trash in a trash can.

~ One patient room dedicated as "ready" for patient use contained a shower that had water spots as if just used.

~ Patient's belongings in a soiled workroom. Staff told the surveyors when patients are discharged from the hospital and leave their personal belongings, the staff would put them in the soiled workroom. The soiled utility room is considered a contaminated area.

~ The nursing staff caring for a patient in isolation discarded their used personal protective equipment outside of the room in the anteroom work area rather than inside the patient room according to national standards of practice.

~ There were 4 wheelchairs in the hallway. Surveyors could not verify if the wheelchairs were clean or dirty. Wheelchairs should be disinfected after each use.

~ The sink outside the isolation room contained blue hand soap in a store bought dispenser. The hand soap smelled like dishwashing soap and lathered up like dishwashing soap. The soap was not in its original container and it could not be determined if the soap was hospital grade antibacterial soap.

~ Through-out the entire facility store bought hand soap dispensers were observed. The soap dispensers contained either a blue soap or an orange soap. On the afternoon of 07/12/2016, staff QQ told surveyors the blue soap was from Eco-lab and the orange soap was bought from the local grocery store. Staff QQ told surveyors the hospital was out of the soap from Eco-lab and had been buying and refilling old used dispensers with soap from the grocery store. Staff could not verify the soap was an anti-bacterial, hospital-grade product. None of the staff could produce the manufacturer's description of the soap to verify it was a medical hand disinfectant product.

~ On the afternoon of 07/12/2016, the Infection Control Practitioner confirmed these findings and told surveyors she had not been involved in the decision regarding store bought soap.

Dietary Department:

~ The freezers in the dietary department were covered in grease and grime on the doors.

~ Two ice filters had turned dark brown (instead of white) and the canister had a sticker dated 10/2015. There was no indication of what the sticker date was.

~ Food items were mixed with cooking items such as pans and spatulas. The close proximity of these items could result in food contamination.

~ There was a designated food storage area but food was stored in other places throughout the kitchen. Proper food storage requires controlled conditions.

~ The kitchen staff hand washing sink was dirty and had food matter covering the drain.

~ There was a milk jug sitting by the kitchen sink. The milk jug was labeled "refill don't throw." The milk jug was filled with a clear liquid. The milk jug contained no label designating what the liquid was. Secondary containers have specific labeling requirements per Occupation Health and Safety Administration (OSHA) guidelines.

~ There was a mold-like substance observed under the sink in the dining room located by the kitchen. The wood surface below the sink was covered with laminate. The laminate was lifting off the surface, is not cleanable.

~ A kitchen inspection report dated 04/07/2016 documented floors, walls and ceilings were in disrepair and were not be adequately cleaned.

Respiratory Department:

~ The respiratory therapist told the surveyors he reprocessed single use circuitry that was used in continuous positive airway pressure (CPAP) machines. He performed this task in a room that was not designed for medical instrument reprocessing. The hospital was not designated by the FDA as a certified medical device reprocessing facility.

~ The respiratory therapist was asked to provide the documentation from the FDA that indicated this single-use patient care equipment could be reprocessed. He stated he did not have any documentation from the FDA or the product manufacturer that stated this item could be reprocessed.

~ A hospital policy titled, "Equipment and Supplies Cleaning and Disposal," documented, "... all items labeled as disposable or single patient use items will be discarded in the appropriate receptacles..."

~ Another policy titled, "Reuse of Limited Use Devices," documented, "... disposable products or products intended for single use shall not be reused, resterilized or reprocessed by the hospital..."

~ Test strips used to test the effective concentration of the high level disinfection (HLD) solution was found opened and undated. The respiratory therapist stated he did not know when the bottle was opened. He stated he did not perform the quality control testing for the HLD test strips. The manufacturer required the quality test to be performed when a bottle was first opened.

~ The respiratory therapist stated he had no formal training on medical instrument reprocessing or high-level disinfection processes.

~ The reprocessing room contained a two compartment sink. There was no provision of separate staff handwashing sink. The room had no handwashing soap and no paper towels.

~ The reprocessing room had a tabletop area that was covered with blue absorbency pads and those pads were in turn covered with white bath towels. The blue pads and the bath towels were dirty with old yellow and brown stains, dust, dirt and debris. The respiratory therapist stated this area was where the "clean" equipment was placed to dry.

Radiology Department:

~ Single-use oxygen extension tubing that was attached to a large oxygen cylinder and was used for multiple patients. The tubing was old and dirty and should have been discarded after one use.

~ Plastic patient pillows stored on dirty surfaces.

~ Patient positioning devices stored in the staff handwashing sink.

~ Dirty pillowcases stored on shelves.

~ Used ace bandages (single-use only) were found rolled up for re-use in the department.

~ Empty glove boxes that had not been replaced. Extra gloves were not found in the department.

~ Clean flat sheets stored on dirty shelves.

~ Sterile blunt needles for injection stored within the splash zone of the staff handwashing sink.

~ An opened bottle of barium suspension for ingestion was found in a dirty, rusted cabinet. This product should have been discarded and not made available for another patient's use.

~ A rusted and dirty biohazardous waste container that could not be adequately cleaned.

~ A bottle of Johnson's Baby Wash at the sink and used by staff for handwashing in the department. No other appropriate hospital-grade handwashing antibacterial agent was available.

~ Torn plastic positioners and padding devices that had exposed inner foam that could not longer be cleaned between patients.

~ Multiple patient and departmental items stored in cabinets under the handwashing sink. Because of the risk of plumbing leaks, undersink cabinetry should not be used for storage.

~ A plastic linen hamper that was visibly soiled with brown material. The hamper had no disposable bag liner and there was dirty linen in the bottom.

~ A patient toilet room in the department contained dollar store hand soap for patient use, instead of hospital grad soap.

~ The patient dressing room had a white pill on the floor and was also filled with old files and broken equipment.

~ A power injector used for CT contrast infusions had dried contrast on the outer casing and within the chambers.

~ The work counter used to prepare IV contrast injections was cluttered with equipment and was visibly dirty.

~ There was no antibacterial hospital grade hand soap in the department for staff to wash hands.

~ Velcro straps were stored in the bowl of the staff handwashing sink. These Velcro straps had been used for multiple patients and could not be cleaned or disinfected.

~ A dead insect was found on the floor of the radiology department for 2 days during the survey.

~ Lead shielding items used for patients and staff were cracked and could not be disinfected between uses. They were visibly dirty and were located as ready for patient use.

~ Expired 50 milliliter intravenous saline solution bags.

~ Expired extravasation patches

~ IV tubing taken out of the sterile packaging and stored in a drawer with the sterile spike exposed.

~ Unfinished plywood shelving that could not be cleaned or disinfected.

~ Two spray bottles that were labeled by the manufacturer as "glass cleaner" were re-labeled in handwriting by staff as "bleach" and "Lysol." The staff used these products to clean the department. The staff were unaware they could not write over a manufacturer's label. They also could not determine when the bottles were filled with bleach or Lysol and were not aware of the concentrations needed for these products to be effective. The infection control committee had not approved these chemicals for disinfection of patient care areas.

~ Throughout the hospital, housekeeping carts had the same re-used spray bottles with unapproved cleaning agents with improper labeling.

Operating Room Department (OR):

~ Multiple alcohol based hand rubs expired 12/14

~ Two expired medications in the crash cart. A policy titled, "outdate and recall policy," documented, "...all medications, supplies, and equipment must be checked for expiration date on a routine basis..." The policy further documented, "...all medications, supplies, and equipment that have reached the expiration date are no longer considered safe for patient use and should be removed from service..."

~ The sterile storage area contained peel packs of sterilized instruments such as scissors, and hemostats stored with the tips closed. This does not allow for complete sterilization, the tips should be open.

~ Opened sterile gloves stored in the OR cabinet in OR 1. Sterilized items that are opened are no longer considered sterile.

~ an opened sterile gastric tube in the anesthesia cart.

~ Laryngoscope blades stored uncovered in the crash cart.

~ Staff H told surveyors laryngoscope blades were cleaned with an enzymatic cleaner by the central sterile technician. (Enzymatic cleaner is used to remove proteins and biofilms from an instrument; it is not used for sterilizing or high level disinfection.)

~ On the afternoon of 07/13/2016, the infection control practitioner told surveyors she thought glutaraldehyde was used to disinfect the laryngoscope blades. Review of the hospital chemical and disinfection product list did not contain glutaraldehyde on the list.

~ On the afternoon of 07/19/2016, Staff K told surveyors Rapicide was use for high level disinfection of the laryngoscope blades. A policy, titled, "Equipment and Supplies Cleaning and Disposal," documented, "...cold sterilization items {high level disinfection} ...examples of items to be cold sterilized include ...laryngoscope blades..."

~ On the 07/13/2016, at 3:15 p.m., surveyors reviewed the sterilizer log. It could not be determined on several days how long the "dry" time was. (Proper drying times are essential to ensure proper sterilization.) Staff Q told surveyors the sterilizer was pre-set and it was always 30 minutes "wet" time and 30 minutes "dry" time. Staff Q told surveyors she had not looked at the manufacturer guidelines for all instruments sterilized. Staff Q told surveyors the hospital followed the sterilizer guidelines. On the morning of 07/13/2016, surveyors reviewed the manufacturer guidelines for the sterilizer. The manufacturer guidelines documented, "...when sterilizing specialty items contact supplier of product for, temperature and exposure time requirements..."

Staff Q told surveyors the recording needle of the sterilizer sometimes got "stuck" and failed to always record the time and duration of sterilization loads.

~ Surveyors toured the endoscopic processing room. Staff Q told surveyors the endoscope flushing pump was flushed with water at the end of each day of use. The manufacturer's instructions for use documented that the inner chamber should be disinfected with high level disinfection followed by defined patterns of air/water/alcohol.

~ There was a paper sign hanging on the wall in the endoscopy procedure room. Paper can't be terminally cleaned.

~ There was a bedside table in the endoscopy procedure room that was rusty. Rust can't be terminally cleaned.

~ There was a leather chair in the endoscopy procedure room that had tape on the arm of the chair. Tape can't be terminally cleaned.

Laundry Room:

~ On the afternoon of 07/12/2016, surveyors toured the laundry department.

~ The Laundry room was split up into two rooms. One room was designated as a clean linen room and one was designated as a dirty linen room.

~ There was a microwave in the dirty room. Staff QQ told surveyors she did not use the microwave.

~ There was an oscillating fan in the dirty linen room. Oscillating fans pose a risk for infection control issues. There was no policy in place to guide the use of the fans in the hospital and to guide cleaning of the fans.

~ There were several bags of linen on the floor in the dirty room. Staff QQ told surveyors the hospital washed linen for another facility. There was no clear designation of which linen was the hospital's linen and which linen was the other facility's linen.

~ There were oscillating fans in the clean linen room. Oscillating fans pose a risk for infection control issues. There was no policy in place to guide the use of fans in the hospital and to guide cleaning of the fans.

~ There were staff lockers and a staff designated refrigerator in the clean linen room. Staff items and patient care items should not be mixed.

~ There were patient personal belongings in the clean linen room. (Personal belongings should be segregated from patient service areas.)

Laboratory:

~ Expired blood collection tubes ready for use on patients.

~ Expired reagent solutions in the blood refrigerator. The reagent was dated as expired in December of 2015.

Physical Therapy Department:

~ Staff were unable to identify which disinfectant was used to clean the Hydrocollator (liquid heating device that is used in physical therapy clinics to heat and store hot packs for therapeutic uses.) There was no policy for disinfecting the Hydrocollator.

~ There was a porous cloth linen hamper that was used to dispose of dirty linen. This container could not be disinfected. The hamper had no plastic liner.

Employee Health:


Twelve employee and medical staff files were reviewed for TB symptom assessments or TB skin testing and reviewed for evidence of adequate immunization status. Nine of twelve employee files had no documentation of current TB skin testing or TB symptoms assessment.


Eight of twelve files had no documentation of immunization records, blood titers or attestation documents.