Based on observation, interview and record review the facility failed to maintain their hemodialysis (removing waste products from the blood) machines in a manner to reduce the risk of infections and potential life threatening reactions for patients receiving hemodialysis in the facility. This failed practice placed all patients receiving hemodialysis at the facility in immediate jeopardy for harm and/or death from chlorine, chloramines and other harmful organic substances potentially entering the blood stream during the dialysis process. The risk of immediate harm to the patients receiving dialysis was reported to the facility's administrative team on 6/30/16 at 9:10 am. The facility removed the immediacy at 6/30/16 at 11:20 am. Findings: Refer to CFR 482.41(c)(2) / A-0724. .
. Based on observation, interview and record review the facility failed to maintain their hemodialysis (removing waste products from the blood) machines in a manner to reduce the risk of infections and potential life threatening reactions for patients receiving hemodialysis in the facility. Specifically, the facility failed to ensure their hemodialysis machines operated with two carbon filters (used to remove impurities from the dialyzing water) in a safe manner and per manufacturer's recommendations. This failed practice placed all patients receiving hemodialysis at the facility in immediate jeopardy for harm and/or death from chlorine, chloramines and other harmful organic substances potentially entering the blood stream during the dialysis process. This failed practice and the risk of immediate harm to the patients receiving dialysis was reported to the facility's administrative team on 6/30/16 at 9:10 am. The facility removed the immediacy at 6/30/16 at 11:20 am. Findings: Observations on 6/27/16 at 2:55 pm revealed 1 patient in the facility's dialysis room receiving hemodialysis. The dialysis room had 6 operating dialysis machines. All the machines had a single carbon tank used to remove chlorine and chloramines from the water. There were no dates on the tanks that indicated the last time they were changed. During an interview on 6/28/16 at 2:00 pm, when asked about the carbon tanks, Biomed Technician #s 1 and 2 stated the carbon tanks were replaced when they were needed. When asked if the carbon tanks were backwashed regularly (flushed to prevent bacterial growth and reticulate carbon) or what the empty bed contact time was, the Biomed Technicians responded they did not know. Review of the preventative maintenance records for the 6 reverse osmosis machines on 6/28/16 revealed only 2 carbon tanks had been replaced between 5/2014 - 3/2016. Review of the manufacturer's instructions provided by the facility revealed Warning: carbon is not regenerated...[Mar Cor Purification-the manufacturer of the water system] strongly recommends the use of two carbon tanks, used in a series configuration. During an interview on 6/30/16 at 11:35 am, the Nephrologist stated he was not aware the facility had only one carbon filtration system for the RO (reverse osmosis-a process of purification using a semipermeable membrane) water. Review of the ANSI/AAMI RD52:2004, 5.2.5 Carbon absorption revealed ...For free chlorine and chloramine removal, carbon absorption systems and carbon media should be selected and configured as described in ANSI/AAMI RD62:2001...That is, two carbon beds [filters] shall be installed in series with a sample port following the first bed... Chlorine/Chloramine Testing Observations on 6/28/16 at 7:30 am after a dialysis machine heat disinfection, revealed Dialysis Registered Nurse (RN) #2 taking water from the dialysis machine without allowing the RO to run to the drain for any time before completing a chlorine/chloramine test. Record review of the Millenium Reverse Osmosis Unit maintenance manual provided by Biomed staff, revealed Product Water Analysis Procedure: Operate the RO unit with product water and waste flows to drain for at least 15 minutes...before drawing sample. Record review of the policy Hemodialysis WaterCulture dated 6/2015, revealed At each point of collection, open the valve and allow the water to flow for a minimum of 2 minutes before the sample is collected. Acid Concentrate Observation on 6/28/16 at 9:30 am revealed multiple Renasol acid concentrate jugs labeled Ca0.0 / K0.0. The acid concentrate jugs were stored adjacent to the standard K2 Ca2.5 jugs of acid concentrate. Leadership was notified on 6/28/16 at 4:00 pm of the acid storage concern because both the lethal acid concentrate and the standard acid concentrate looked identical with red and white labels. On 6/29/16 at 8:00 am the acid concentrate had not been removed from the storage area. New Dialysate Meter Observation on 6/28/16 at 7:30 am revealed a minion dialysate meter without a preventative maintenance label. During an interview at the same time, Dialysis RN #4 stated it was recently new to the department. During an interview on 6/29/16 at 9:30 am Biomed Technician #1 stated the biomed department had no record of the new minion dialysate meter and therefore could not ensure the reliability of the equipment. Hemodialysis Competency During an interview on 6/28/16 at 2:10 pm Biomed Technician #s 1 and 2 stated they had not had any education or certification for hemodialysis water maintenance. In addition, they stated the one dialysis nurse that did have knowledge was no longer employed at the facility. Record review of the dialysis competencies provided for the staff currently working on the dialysis unit, revealed all competencies were self competencies for hemodialysis. One staff member had completed multiple ongoing educations in other states. In addition, no staff were certified hemodialysis technicians, to include biomed staff. . .
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. Based on document review, and interview the hospital failed to ensure 100% compliance with the infection control COVID-19 vaccination requirement. Specifically, the hospital failed to ensure all staff had either been fully vaccinated, or had an exemption or accommodation, as authorized by law, granted. Failure to meet the requirement may place staff and patients at greater risk for [DIAGNOSES REDACTED]-CoV-2 exposure and infection. Findings: Review of the hospital vaccination status list, provided on 2/24/22 and 2/28/22, revealed a compliance rate of 97.8%. The list documented 1540 colleagues in total, 1506 have either been vaccinated, partially vaccinated, have an exemption or one pending. There were 34 with no record or missing documentation. An interview on 2/24/22 at 1:44 PM, Case Manager #2, who was on the vaccination status list with no record confirmed he/she worked as a case manager and confirmed he/she had declined the vaccination and was in the process of submitting an exemption request. CM #2 also confirmed the facility had provided education on the vaccine during orientation and with the employee health nurse and through a newsletter. Further stating the hospital had offered the vaccine to him/her when hired. An interview on 2/24/22 at 3:40 PM with Human Resource #1 (HR), responsible for tracking vaccination status of all hospital staff, confirmed the current rate of compliance was less than 100%. FS #1 stated there was a plan in place to achieve 100% compliance, to include the on-boarding process for new hires requiring vaccination or exemption; leadership conducting face to face conversations with staff daily to either complete the vaccination or request exemptions; emails and newsletters are utilized to ensure staff are notified. During this interview the Director of Quality confirmed the facility was actively engaged in meeting the 100% compliance. Administration, department, and unit leaders are all involved working with staff to meet the requirement. Observations on 2/23/22 and 2/24/22 throughout the facility revealed staff providing direct patient care and other staff wearing masks, performing hand hygiene. .
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Based on record review and interview the facility failed to ensure 1 patient (#11), of 22 reviewed, who presented to the Emergency Department (ED) for an emergency medical condition, was offered a medical screening exam (MSE). This failed practice caused a delay in intervention and treatment and potentially delayed emergency responders transporting the patient, from responding to other calls. Findings: Review of a facility reported incident on 10/05/21, revealed on September 1st at 10:57 PM ARH [Alaska Regional Hospital] went on full hospital closure ...at 11:15 PM on September 1st, the Anchorage Fire Department (AFD) EMS [emergency management system] radioed to ARH indicating they were transporting a Patient to the department from the Department of Corrections (DOC). The Patient was a [AGE]-year-old male with a chief complaint of chest pain, [shortness of breath], hypertension [high blood pressure] ...employee who received the EMS radio communication did not reiterate that ARH was on closure per the earlier notice to the AFD dispatch. At 11:19 PM EMS arrived at ARH's ambulance bay. As the EMS crew prepared to unload the patient the Emergency Department (ED) Charge Nurse [Licensed Nurse (LN) #3] presented to the ambulance bay and explained to the crew the hospital is on hospital closure and the ED could not accept the patient. The EMS crew then departed to [Hospital B]. The following morning (September 2nd), AFD notified ARH's EMS Outreach Manager of the event that had occurred. Timeline [10:55 PM]-Administrator on call notified of ARH's capacity status and the decision was made to put the ARD on closure due to capacity. [10:57 PM]-Hospital listed in AFD Dispatch status board as closed [11:15]-Medic 1 radioed report, report accepted by ARD ED staff (did not indicate facility closure). [11:19 PM]-Medic 1 arrived in ambulance bay and met by [Licensed Nurse (LN) #3]. [11:21 PM]-Medic 1 departed ARH ambulance bay and proceeded to [Hospital B]. ARH the entered the patient on its Central Log as a John Doe. Further review of the facility reported incident revealed The Following Correction Actions Have Been taken: 1. [Name] Chief Executive Officer [CEO] and [Name] Chief Medical Officer [CMO] for ARH contacted AFD [Anchorage Fire Department] Battalion Chief [Name] and Fire/EMS Operations Medical Director [Name], on September 2nd to follow up on the occurrence and be transparent about what occurred. 2. Also on September 2nd, during the daily 'Huddle' with all department leadership and/ or representatives, [name] Ethics and Compliance officer educated staff on EMTALA [Emergency Medical Treatment and Active Labor Act] using this incident as a learning tool. The 'ask' was to take back the information and begin the re-education of staff. 3. Workforce members are being re-educated on ARH's EMTALA Medical Screening Exam Policy. This will include ED Nurses, House Supervisors, Patient Care Attendants and Certified Nurse Aides and is now in process. 4. Re-education will include any and all ED staff authorized to meet EMS at the ambulance bay and to stress that even if ARH is on closure or diversion, if EMS shows up, the patient has 'presented to the ED', EMTALA applies and the required MSE and stabilizing treatment will be given. ED Charge Nurses will communicate at department huddle. There will also be individual rounding with ED employees on EMTALA as directed by the chief nursing officer. 5. Doctor [CMO] will bring awareness of the incident provide re-education of ARH's EMTALA policies to ARH's emergency room physicians. Record Review: On 10/5/21, review of the Emergency Medical Treatment and Active Labor Act [EMTALA] emergency Department [ED] log at ARH revealed Patient #11 was listed under a pseudonym. On 9/01/21 at 11:19 PM: Patient arrived in ED 11:21 PM: Patient dismissed Emergency Medical Services (EMS) Report Review of the receiving hospital [Hospital B] records on 10/8-9/21 identified the John Doe as Patient #11. Review of the AFD Patient Care Report, on 10/9/21, revealed Patient #11 was picked up from the Anchorage Correctional Complex on 9/01/21. The EMS arrived on scene at 10:58 PM, transported the Patient at 11:13 PM, and arrived at the initial hospital at 11:20 PM. Arrived at Hospital B at 11:29 PM. Review of the Narrative revealed: S [subjective]: This is a [AGE]-year-old M with CC [current complaints] of chest pain, SOB [shortness of breath], and coughing blood. This Pt. [patient] States earlier today he began complaining of heavy chest pain in the middle of his chest radiating to his shoulder. He states mild SOB and that he coughed up a small about a blood. The Pt. Also states he was at the hospital earlier today and received multiple units of blood products for anemia. He was not admitted to the hospital and the corrections officer cannot verify the patient story. This Pt. is frequently transported by EMS for similar episodes. The Pt. denies N/ V, dizziness [illegible] symptoms. He has a history of HTN [high blood pressure], CVA [stroke], COPD [Chronic Obstructive Pulmonary Disease], diabetes, heart attack, anemia [low iron in the blood], and CRF [chronic kidney failure] .... A [assessment]: chest pain P [plan]: assessment, VS, loaded to stretcher to MICU [medical intensive care unit], transport code yellow status 3, repeat VS enroute. Pt. was transported to ARH ER. On arrival to ARH ER the staff met us at the ER MICU Bay stating they cannot accept the patient due to being on full closure. They advised us to transport the Pt. to [Hospital B] ER. On arrival to [Hospital B] ER moved Pt. to triage. Pt. report at bedside to ER staff. PT. care transferred at that time without incident. Review of the timeline revealed EMS arrived at the second destination with Patient #11 at 11:29 PM, 9 minutes after departing from ARH. Hospital B Records Review of the Patient #11's medical records from Hospital B on 10/06/21, revealed the Patient arrived at the ED on 2/01/21 at 11:33 PM. Review of the Emergency Department Record, performed at Hospital B on 9/02/21 revealed [Patient #11] is a 73 yo male who presents with chest pain and shortness of breath. Patient states that around 7 PM tonight he started to have chest pressure on the left side of his chest like an elephant sitting on his chest. This is similar to a prior heart attack that he had many years ago. He has not had any worsening of the symptoms with exertion or movement of his arms. He has had numbness along his right upper shoulder and started having nausea and vomiting with blood- tinged vomit. He has had shortness of breath since that time as well. ... He was not seen by the medical staff at jail until 11:00 PM tonight he has been receiving his medications normally ...The most recent note in our system is from being seen in February 2021 for a left heart Cath [insertion of a catheter into the heart]. He did not have obvious chest pain due to coronary [heart] insufficiency and no evidence of spasm. They found mild CAD [coronary artery disease] in all vessels and only moderate disease at 50% in the diagonal vessel... Looking in care everywhere I do not see any lab test or other work up since June 2021 at Alaska Regional Hospital. Interviews During the entrance interview on 10/05/21 at 9:15 AM with the CEO, CMO, and Quality and Risk Manager, the CEO stated the facility learned of the event the next morning when they were contacted by the AFD. The CEO stated the facility immediately ensured all the staff were reeducated in EMTALA requirements and understood a patient presenting to the ED with the medical emergency had a right to a medical screening exam. Someone had responded to the EMS call and forgot to remind them the hospital was on a closure status (so the patient could go to the next available hospital). The Charge RN [LN #3] on that night had met the ambulance in the bay and had sent it on to the next hospital. During an interview in the ED on 10/05/21 at 9:40 AM, ED Tech #1 stated when patients present to the ED, he/she will ask their name and why they are here. The ED Tech stated he/she also attempts to ask COVID screening questions prior to obtaining their vital signs. If the bays were open the patients were immediately brought back by the triage nurse. Observations during the survey on 10/5/21 at 10:00 AM revealed the emergency calls came in via the call center located at the main nurses' desk in the ED. During an interview on 10/05/2021 at 10:00 am, the Director of Emergency Services (DES) stated there are currently 20 relief, or travel, nurses from the lower 48 working within the facility. She further stated the orientation for these relief, or travel, nurses consisted of a HealthStream orientation (consisting of an array of topics), a check off high acuity nursing competencies, and one or two shadow shifts with a full time RN. The DES stated she was responsible for ensuring staff met the EMTALA requirements, triaging, nursing care, scheduling, quality assurance review, well as the supervision & administration of the unit including the integration of the department into the primary functions of the hospital. During an interview on 10/06/21 at 10:00 AM, LN #1 stated when calls from EMS to the nurses' desk. The nurses respond and get the status of the patient. Nursing staff were also responsible letting EMS know if the hospital were on closure or recovery, so EMS could route to next open hospital. If all the hospitals were closed the hospitals took turns taking patients. The LN stated the hospital had recently provided additional EMTALA education. During an interview on 10/05/21 at 10:15 AM, LN #2 stated EMTALA training was done online by the HealthStream program, the LN stated he/she had recently completed education. During an interview on 10/06/21 at 1:25 PM, the ED Medical Director stated he was aware of the EMTALA violation had a meeting with the medical staff regarding the event. He stated he planned to do more formalized education for physicians in the future. During a second interview on 10/06/21 at 4:15 PM, the DES stated the AFD reached out to EMS Outreach Manager (LN #4) the next morning. The DES stated the medical team had audited the call that came in and reviewed the EMTALA event. The DES stated although LN #4 had documented on Patient #11, it was LN #3 that had met the ambulance in the bay. Review of the facility policy EMTALA Medical Screening Exam, approved 2/23/21, revealed An EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED) and: 1. The individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition; or 2. A prudent layperson observer would conclude from the individual's appearance or behavior that the individual needs an examination or treatment of a medical condition. Review on 10/06/21 of the facilities. Emergency Medical Treatment and active Labor Act [EMTALA], undated, the training provided to nursing staff, revealed Emergency Department Obligations Patient or representative request medical care. Hospital must provide medical screening exam. Review of the reeducation on EMTALA requirements, provided to ED nursing and non-nursing staff, revealed all scheduled staff had completed the training by 9/07/21. .
. Based on interview, record review and observation the facility failed to ensure the safety of 1 Patient (Patient #10) admitted to the Emergency Department (ED). Specifically, the facility failed to conduct post fall assessments for 1 patient (out of 8 sampled patients with falls). This failed practice placed patients at risk for less than optimal health outcomes. Findings: During a telephonic interview on 11/20/18 at 2:30 pm with Patient #10, he/she stated he/she had fallen in the ED at Regional Hospital. Specifically, Patient #10 stated he/she was walking from the exam room to the bathroom and fell to the floor. Record review on 1/16-18/19 of Patient #10's medical record revealed no evidence of a fall; post fall assessment or follow-up during his/her stay at the facility's ED. Observation on 1/17/19 of the facility's security video dated 10/11/18 at 2:00 pm, from the ED, revealed Patient #10 ambulating towards a bathroom from his/her room unassisted and fell to the floor. Interviews on 1/17/19 at 3:15 pm, with the Director of Patient Safety & Risk Management and the Director of Emergency Services confirmed Patient #10 fell in the ED on 10/11/18 at 2:00 pm. Further interviews with the Director of Patient Safety & Risk Management and the Director of Emergency Services confirmed there was no documentation in the patient's record indicating a fall on 10/11/18. When asked if staff should have documented the fall and provided follow up care, both confirmed documentation should have been in Patient #10's Electronic Medical Record. During an interview with ED Physician #1 on 1/18/19 at 11:20 am, he/she stated the expectation after a patient's fall would be the physician re-evaluated the patient and documented the findings. In addition, he/she stated the fall, re-evaluation and follow up should have been documented in both the physician notes and the nurses' notes. He/she also stated it is the expectation to document an addendum to the patient's chart if the physician didn't document during the ED visit. Review of the facility policy number HOSP.902.560 effective date 8/2018, titled Fall Prevention Program revealed the following: OUTPATIENT - EMERGENCY DEPARTMENT 1. In the Emergency Department, all patients are considered to be at risk for falling. Additional fall precautions are implemented per nursing judgement and patient assessment. 2. If a patient falls, a post-fall assessment, including vital signs and provided notification must be documented. 3. If a patient falls, a detailed nursing note must be entered in the patient record including, the date and time of fall, description of the fall, results of the post-fall assessment and any notifications that have occurred. 4. If a patient falls, include risk for injury into the patient care plan. 5. If a patient falls, add 'fall during hospital admission' into Admission History. This will show on the patient's history for future admissions. 6. If a patient falls, complete an occurrence report and the post-fall debrief form. Return to manager or house supervisor. .
. Based on record review, observation and interview the facility failed to ensure medical records were completed for 1 Patient (Patient #10), out of 20 sampled patients, whose records were reviewed. Specifically, the facility failed to document in Patient #10's record a fall experienced in the facility Emergency Department (ED) and any follow up assessments or care related to the fall. This failure had the potential to negatively impact the patients' future medical care. Findings: Record review on 1/16-18/19 of the patient's medical record revealed no evidence or documentation of a fall on 10/11/2018 while seeking care as an outpatient in the facility ED. Observation on 1/17/19 of the facility's security video dated 10/11/18 from the ED revealed Patient #10 ambulating in the hall unassisted and falling to the floor. Interviews on 1/16-18/19 with the Director of Emergency Services and the Director of Patient Safety & Risk Management confirmed no documentation in the patient's record indicating a fall on 10/11/18. When asked if staff should have documented the fall and any follow up care, both confirmed documentation should have been in the patient's chart. During an interview with ED Physician #1 on 1/18/19 at 11:20 am, he/she stated the expectation after a patient's fall would be for the physician to re-evaluate the patient and document the findings. In addition, he/she stated the fall, re-evaluation and follow up should be documented in both the physician notes and the nurses' notes. He/she also stated it is the expectation to document an addendum to the patient's chart if the physician didn't document during the ED visit. Review of the facility policy number ED.103.003, effective date 6/2016, titled Medical Record, Emergency Department revealed under section 4; Each time a patient visits the Emergency Department, the following information is entered in the patient's medical record: subpart C; clinical observations, including response to treatment and medication effects. Review of the facility policy number HOSP.902.560 effective date 8/2018, titled Fall Prevention Program revealed the following: OUTPATIENT - EMERGENCY DEPARTMENT 1. In the Emergency Department, all patients are considered to be at risk for falling. Additional fall precautions are implemented per nursing judgement and patient assessment. 2. If a patient falls, a post-fall assessment, including vital signs and provided notification must be documented. 3. If a patient falls, a detailed nursing note must be entered in the patient record including, the date and time of fall, description of the fall, results of the post-fall assessment and any notifications that have occurred. 4. If a patient falls, include risk for injury into the patient care plan. 5. If a patient falls, add 'fall during hospital admission' into Admission History. This will show on the patient's history for future admissions. 6. If a patient falls, complete an occurrence report and the post-fall debrief form. Return to manager or house supervisor. .
. Based on record review, interview and video review the facility failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital's emergency department to determine whether or not an emergency medical condition exists for 1 (#21) prospective patient out of 21 emergency room visits reviewed. This failed practice resulted in the patient not receiving a medical screening exam to rule out an emergent medical condition. Findings: Record review on 9/25-27/18 of the emergency department patient log expanding 6 months prior to survey dates revealed prospective patient #1 was not listed as being triaged, evaluation, admitted or transferred by the facility's emergency department. During an interview on 9/26/18 at 2:37 pm Witness #1 stated he/she presented to Alaska Regional ED, on 9/11/18 sometime around 5:00 pm with the Prospective Patient (#21), as an escort. He/she noted the ED waiting room wasn't busy. Witness #1 stated he/she approached the triage window and asked the triage LN if his/her client could be seen for a psychiatric evaluation. In response, according to Witness #1, the triage nurse stated You will have to go somewhere else because the facility didn't have a doctor that did that [psychiatric evaluations]. According to the Witness he/she stated Alright, thank you. and then exited the ED with the prospective patient. He/she further stated the interaction from the time he/she walked in until the time he walked out was about 1-1.5 minutes. The prospective patient was never screened or evaluated by any medical staff. Once the Witness and Patient #21 left the facility, they went to another local hospital where the prospective patient had a significant loss in mental stability and became very violent. A camera review was conducted on 9/27/18 at 1:10 pm with Security Officer and Compliance/Quality Officer staff present. Review of ED entrance/waiting area video (entering from hospital entrance through ED waiting area toward triage window) on 9/11/18 at 4:54 pm revealed Witness #1 and Prospective Patient #1 entered to the ED waiting room approached the triage window area. After a brief moment at the triage window area the two individuals left. The total time between entering the ED area and exiting the area was 1 minute. The triage window was unable to be viewed by any camera view. Review of the ED staff assignment sheet, dated 9/11/18, revealed Licensed Nurse (LN) #2 was listed as being the triage nurse for that day, during the day shift. During an interview on 9/27/18 at 1:10 pm, LN #2 was asked if he/she was working on 9/11/18 at approximately 4:30 pm to 5:30 pm. LN #2 stated he/she didn't recall but if the ED staff assignment sheet stated he/she was assigned to triage, then he/she worked triage that day. When asked what the process was when a patient was checked into ED with psychiatric concern, LN #2 stated they would set the patient up with tele-psych, conduct an evaluation, and may need to make a referral to other resources. During the same interview, LN #2 stated ED did not log in anyone until they got a name, come into triage area or wrote on the standardized ED form and brought it back to the triage LN. When shown a picture of the prospective patient, the LN stated he/she did not remember seeing him/her that day or speaking to anyone about a psychiatric evaluation. LN #2 further stated if someone wanted to be evaluated for psychiatric concerns they should have been checked in and evaluated. Review of the facility's policy entitled EMTALA Medical Screening Exam, review date of May 2018, revealed An EMTALA obligation is triggered when an individual comes to a dedicated emergency department ('DED') and ...the individual or representative acting on the individual's behalf request an examination or treatment for a medical condition ...A hospital must provide an appropriate MSE within the capability of the hospital's emergency department ...to determine whether or not an [emergency medical condition: EMC] exists ...an individual who has such a request made on his or her behalf ...an individual whom a prudent layperson observer would conclude from the individual's appearance or behavior needs an MSE. An MSE shall be provided to determine whether or not the individual is experience an EMC ... Review of the facility's policy entitled Triage Area Responsibilities, dated March 2016, revealed ...All patients will receive a medical screening exam by a physician ...Upon arrival to the Emergency Department, patients are assessed for priority of care. The first point of contact upon entrance to the Emergency Department is a triage nurse.
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. Based on record review and interview the facility failed to ensure evidence the right to formulate Advanced Directives was offered for 2 patients (#s 1, 3), out of 10 sampled patients. This failed practice had the potential to deny the patients the right to choose and make end of life medical care decisions. Findings: Patient #1 Record review on 8/8-10/18 revealed Patient #1 was admitted to the facility on [DATE] with diagnoses that included kyphoscoliosis (curvature of the spine) and radiculopathy (injury to a nerve or root) of the lumbar/sacral region of the spine. Review of the Conditions of Admission and Consent for Outpatient Care form signed by the Patient on 1/11/18 revealed the Patient did not acknowledge the information about Advance Directives under number 16 of the form. The form stated ...I have furnished information regarding Advance Directives (such as durable power of attorney for healthcare and living wills ...Please initial or place a mark next to one of the following applicable statements: .... There were 3 boxes: 1. I executed an Advance Directive and have been requested to supply a copy to the hospital. 2. I have not executed an Advance Directive, wish to execute one and have received information on how to execute an Advance Directive. 3. I have not executed an Advance Directive and do not wish to execute one at this time. The Patient had not marked any of the applicable statements. Patient #3 Record review on 8/8-10/18 revealed Patient #3 was admitted to the facility on [DATE] with diagnosis that include Legionella Pneumonia and Acute Respiratory Distress. Review of the Conditions of Admission and Consent for Outpatient Care form signed by the Patient on 7/19/18 revealed the Patient did not acknowledge the Advance Directives information under number 16 of the form. The form stated ...I have furnished information regarding Advance Directives (such as durable power of attorney for healthcare and living wills ...Please initial or place a mark next to one of the following applicable statements: .... There were 3 boxes: 1. I executed an Advance Directive and have been requested to supply a copy to the hospital. 2. I have not executed an Advance Directive, wish to execute one and have received information on how to execute an Advance Directive. 3. I have not executed an Advance Directive and do not wish to execute one at this time. The Patient had not marked any of the applicable statements. During an interview on 8/10/18 at 10:15 am with the Director of Patient Access when asked if one of the boxes on the aforementioned form should be filled out by the patient, the reply was yes. Review on 8/10/18 of the facility's policy and procedure Patient Rights & Responsibilities dated July 2018, revealed We adopt and affirm as policy the following rights of patients/clients who receive services from our facilities:...Decision Making and Notification...To formulate advance directives... .
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. Based on record review and interview the facility failed to ensure the plan of care identified skin integrity concerns for 2 patients (#s 1 and 3) out of 10 sampled patients. The failure to ensure the care plan identified skin integrity concerns placed the patients at risk for skin integrity issues not being identified and treated. Findings: Patient #1 Record review on 8/8-10/18 revealed Patient #1 was admitted to the facility on [DATE] with diagnoses that included kyphoscoliosis (curvature of the spine) and radiculopathy (injury to a nerve or root) of the lumbar/sacral region of the spine. Further review revealed the Patient was transferred to a rehabilitation facility on 1/18/18. Review of the medical records nursing notes from the admitting facility dated 1/18/18, revealed ...Multiple wounds present ...Also present was suspected DTIs [deep tissue injuries] on bilateral [both] heels and the lateral aspect of the left midfoot... Review of the nursing Plan of Care from 1/12-18/2018 revealed no problems with skin integrity (integumentary system) was identified on the nursing plan of care. Review of the Integumentary (skin) flow sheets for the period 1/12-18/18, revealed no documentation of any skin issues on the bilateral heels. The flow sheets did identify skin alterations of abrasions on face, chest and lower abdomen. Review of the Discharge Summaries from the physician dated 1/18/18 at 7:52 am, revealed no documentation of pressure injuries. During an interview on 8/10/18 at 9:00 am, Charge Nurse (CN) #2 stated the nurses should do a head to toe skin assessment 1 time per shift and upon discharge. The CN stated the skin assessments included the heels. The CN further stated any skin risks or wounds should be on the plan of care. The CN confirmed there were no skin issues on the nursing plan of care in the electronic medical record (EMR). Patient #3 Record review on 8/8-10/18 revealed Resident #3 was admitted to the facility on [DATE] with diagnosis that include Legionella Pneumonia and Acute Respiratory Distress. Review of the medical record nursing notes dated 8/3/18 at 3:00 pm, revealed Left ear unstageable pressure injury...area measures 1.5x1cm... area purple and yellow... Review of the nursing Plan of Care dated 7/20/18 to 8/8/18 revealed no problems with skin integrity was identified on the nursing plan of care. Review of the ICU/Pulmonary Attending Progress Note from the physician dated 8/6/18 at 2:42 pm, revealed no documentation of pressure injuries. Review of the Discharge Summaries from the physician dated 8/8/18 at 3:12 pm, revealed no documentation of pressure injuries. During an interview on 8/10/18 at 8:15 am with RN #2, when asked if the patient's pressure injury should have been added to the care plan, the response was ideally, yes. Review on 8/10/18 of the Standards of Care for Orthopedic Unit dated May 2016, revealed ...The RN will update and prioritize the care plan every shift and prn [as needed] with a change in the patient's status...Wound assessment and documentation every shift and prn as needed... .
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
. Based on observation, record review and interview, the facility failed to ensure 2 topical steroid medications included the application for use. Specifically, the facility failed to include the location where to apply the topical medications for 1 patient (#9) out of 2 patients observed during a medication pass. Findings: Record review on 8/9-10/18 revealed Patient #9 was admitted to the facility on [DATE] with diagnoses that included [DIAGNOSES REDACTED] Observation during a medication pass on 8/9/18 at 8:30 am, revealed RN #1 omitted 2 topical steroid medications, hydrocortisone 1% ointment and triamcinolone 0.1% cream due to Patient #9's refusal. The RN did not ask the Patient where the medications were to be applied. Record Review on 8/9/18 of the medication orders revealed the following medications: Hydrocortisone 1% ointment, Frequency: Daily Triamcinolone 0.1% cream, Frequency: 2 times daily. The start for both topical medications was 7/31/18. There was no information regarding where to apply the topical medications. Further review of the medication administration record (MAR) revealed the Patient received hydrocortisone cream on 2 out of 9 days, on 8/6/18 and 8/7/18. The triamcinolone cream, was given 6 out of 18 times on 7/31/18 at 9:51 pm; 8/2/18 at 8:45 am; 8/6/18 at 8:42 am; 8/7/18 at 9:57 am; 8/7/18 at 8:00 pm; and 8/8/18 at 8:17 am. The missed topical medications were documented as Missed Patient/family refused. Additionally, the MAR for the triamcinolone cream on 8/8/18 at 8:26 pm, revealed the RN wrote Ordered for itch on R [right] leg, pt [patient] denies itchiness. Review of the physicians progress note dated 8/9/18 at 1:36 pm, revealed ...has chronic [DIAGNOSES REDACTED] [redness] in her armpits, and below breasts, and I clarified with RN regarding hydrocortisone cream, and triamcinolone use... During an interview on 8/9/18 at 2:25 pm, Charge Nurse (CN) #1 confirmed the order was missing the information on where to apply the medication. The CN stated the RN or provider could put in the information. During an interview on 8/10/18 at 10:25 am, the Pharmacy Director (PD) stated the order/MAR should have indicated the location the topical medications should be applied. The PD stated the Pharmacy should double check the orders. Review of the facility's policy and procedure dated November, 2012 and the policy and procedure under revision dated August 2018, revealed ...Incomplete/Illegible Orders: Orders that are incomplete, illegible or unclear are to be clarified with the prescriber. No order will be processed until it is clear and complete. .
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
. Based on record review and interview the facility failed to investigate and respond to a complaint that was called in, via telephone, to Risk Management. Findings: Review of the online complaint, submitted to the State Agency on 12/29/17, revealed the complainant had made several calls to the hospital on [DATE] and left messages with Risk Management. The complainant received a return call from the Patient Safety Director (PSD) on 10/3/17. The complainant stated the PSD told her she would take the information and report it as a complaint and it would be reviewed by risk management staff, nursing leadership, and that family member would receive a call back to discuss further with me and/or the POA [Power of Attorney]. The complainant stated I never received a return call and the POA was never contacted. Patient #1 was admitted on [DATE] with diagnosis of acute hypoxic respiratory failure; shock and pneumonia. Record review of the Patient Compliant/Grievance Log from 9/1/17 to 1/28/18 revealed no documentation of the complaint that was called in regarding Patient #1. On 2/1/18 at 9:50 am an interview with Patient #1's family revealed no one in the family had received any information or follow up regarding the complaint filed. During an interview with Patient Safety Director on 2/1/18 at 10:05 am she stated I do not remember that phone call at all. In addition she confirmed that the complaint was not included on the grievance log, the complaint was not investigated, and no written or verbal response to the grievance was given to the complainant. Review of the facility's policy Patient Complaints/Grievances, Handling and Resolution of, last updated August 2016 revealed: ...5. Upon receipt of a grievance, the Chief Patient Safety Officer shall confer with the appropriate Department Director as soon as possible, to review, investigate and resolve with the patient and/or patient representative within 7 working days ... and ...6. If the grievance will not be resolved immediately, or if the investigation will not be completed within 7 working days, the complainant should be informed that the facility is still working to resolve the grievance and that the facility will follow-up with a written response within 21 days. And ...4. In response to grievances, the hospital shall provide the complainant with written notice of its decision and grievance resolution. .
. Based on interview, record review and observation of inpatient and outpatient admission information given to patients, the hospital failed to: 1) provide to patients the hospital grievance procedures for handling patient's complaints; 2) provide the State Agency (SA) contact information and/or correct SA contact information to patients; 3) provide a working phone number for the Regional Office for Civil Rights U.S. Department of Health and Human Services; and 4) post patient rights signage in the hospital per hospital policy. These failed practices denied patients/families: 1) a clearly explained procedure for submitting a complaint/grievance and 2) an opportunity to contact the SA and the Regional Office for Civil Rights for complaints/grievances. Findings: Patients Receiving Patient Rights Information Patient #18 During an interview on 6/28/16 at 9:20 am in the outpatient Infusion Center, Patient #18 was asked if he had received patient rights information, and if he knew he could contact the SA if he had a concern or complaint regarding his care at the hospital. He said if he had received patient rights information he didn't know he did. He also said he didn't know he could contact the SA. Patient #19 During an interview on 6/28/16 at 11:28 am, Inpatient #19, when asked if she had received information on patient rights or how to report grievances to the SA, she replied I don't recall any information given to me or any telephone numbers for State Agency. Patient #20 During an interview on 6/27/16 at 3:20 pm Inpatient #20, when asked if she had received information on Patient Rights, she stated that no one had told her anything about patient rights. When asked if she had received any information on how to report a grievance to the SA, she stated that no one told her about reporting grievances to the State Agency. Patient #32 During an interview on 6/28/16 at 2:00 pm Inpatient #32 was asked if he had received information on patient rights, and if he knew he could contact the SA if he had a concern or complaint, the Patient stated he didn't know he could call the SA for complaints, I didn't get that information. Review of the hospital policy Patient Complaints/Grievances, Handling and Resolution effective date November 12, revealed ...Each patient and/or the patient's representative will be informed of the grievance process, including whom to contact to file a grievance or complaint. The patient will be informed that a grievance may be directly lodged with the Alaska State Department of Health [Health Facilities Licensing and Certification] regardless of whether he/she has first used the organization's grievance process. This information will be contained in the Patient's Rights and Responsibilities written handout, which will be given out to all patients and/or to their representatives... Review of the hospital's PATIENT'S RIGHTS, RESPONSIBILITIES & RESOLUTION OF COMPLAINTS, given to patients on admission as an inpatient or outpatient, revealed inconsistent and missing information for the hospital's grievance process and contact information for the SA. The patient right's paperwork revealed: 1) the incorrect address and phone number for the SA; 2) it did not list the SA as an option for patients to contact for concerns, complaints, or grievances; and 3) an incorrect phone number for the Regional Office for Civil Rights U.S. Department of Health and Human Services. Patient Rights Posted Random observations from 6/27-30/16 throughout the hospital revealed patient rights were not posted in any patient care areas. During an interview on 6/28/16 at 10:50 am, Charge Nurse #1 stated the Patient Rights and Responsibilities signage was not posted in any of their units. They took it off and never put it back after remodeling [2 years ago]. Review of the hospital's Patient Rights & Responsibilities (Adult & Pediatric/Neonatal), dated June 2013, revealed Patient Rights will be posted in the Emergency Department and Labor & Delivery...Patient Rights and Responsibilities' Statement...will be posted in public areas throughout the hospital. .
. Based on interview and record review the hospital failed to ensure implementation of an effective grievance process, evidenced by failing to ensure staff reported patients grievances to the appropriate person to be investigated. This failed practice had the potential to place patients at risk for delayed investigations and responses to patient concerns. Findings: Patient #20 During an interview on 6/27/16 at 3:20 pm when questioned about the care she'd received, Patient #20 stated, on 6/25/16 she had told two different dietary staff that she had a corn allergy. Her meal selection for dinner was for French fries but on her dinner tray there was corn substituted for the French fries. She stated she was really disappointed with that incident. During an interview on 6/28/16 at 12:30 pm Charge Nurse (CN) #1 confirmed a grievance report had not been completed for Patient #20's complaint regarding her food allergy even though she was made aware of the incident the following day. During an interview on 6/29/16 at 1:20 pm, the Risk Manager (RM) said she reviewed and investigated all patient complaints/grievances. She said she didn't know about Patient #20's complaint until 6/28/16 when Dietary and CN #1 reported it to her, after the Surveyor spoke with them. Patient #32 During an interview on 6/28/16 at 1:50 pm, Patient #32 was asked if he had any concerns or complaints about his hospital stay. The Patient said he had a complaint about one of the nurses taking care of him. The Patient said the nurse yelled at him several times one night because the Patient's television was so loud it prevented the RN from doing his work. The Patient said he told another nurse about the incident and someone from higher up spoke to him about it. The Patient said he didn't know if it was investigated or not. He never heard back from anyone. During an interview on 6/29/16 at 1:20 pm, the RM said she didn't know about Patient #32's complaint but she should have known about it. In a follow up interview on 6/30/16 at 1:00 pm, the RM stated the Nurse Manager (NM) #1, of Cardiovascular Unit (CVSU) had spoken to the Patient about his complaint. NM #1 confirmed the complaint was not reported to the RM. Review of the hospital policy Patient Complaints/Grievances, Handling and Resolution of..., dated November 2012, revealed ...Employee Receiving Grievance Documents the concern on the Patient Grievance Form...Forwards the grievance to the Director of Risk Management immediately... .
. Based on observation, interview and record review the hospital failed to provide dignity and respect for 2 patients residing on the Surgical Progressive Care Unit (SPCU) and Cardiovascular Unit (CVSU). These findings denied the patients their right to dignity and privacy. Findings: During an observation on 6/28/16 at 11:06 am Patient #10 was observed walking in the SPCU hallway with 2 nursing staff by his side. The Patient's gown was open in the back exposing his backside. During an observation on 6/28/16 at 1:45 pm, Patient #32 was observed walking in the CVSU hallway carrying his uncovered completely full Foley catheter bag, with urine in the catheter tubing, in one hand and holding his hospital gown closed behind his back with the other hand. At one point the Patient stopped in front of the nurse's station and spoke to RN #2 telling her he had been waiting to get his catheter bag emptied. After the encounter the Patient left the RN and continued walking around the unit. During an interview on 6/28/16 at 1:50 pm when asked, Patient #32 said he had been waiting close to an hour to get his catheter bag emptied. He said he had the same problem yesterday with the catheter bag being full of urine and no one to empty it. Observation on 6/28/16 at 2:20 pm in the CVSU revealed, RN #2 going into Patient #32's room and shutting the door, 35 minutes after the Patient requested someone empty the foley bag. Review from 6/27-30/16 of the PATIENT'S RIGHTS, RESPONSIBILITIES & RESOLUTION OF COMPLAINTS PATIENT RIGHTS, revealed ...As a patient at this facility, you have the right to...treatment and services that respects your dignity... .
. Based on observation and policy review, the hospital failed to maintain the confidentiality of 2 patients protected health information in the critical care unit (CCU). Specifically, the hospital failed to protect the patient's personal identifiers; name; medical record number; date of birth; physician name; etc. This failed practice had the potential for unauthorized individuals to access patient's personal information. Findings: During an observation on 6/27/16 at 3:20 pm in the CCU revealed plastic bins attached to the wall behind the nurses station, which was directly in front of the main entrance into the unit. The bins contained patient information. While standing at the nurses station this Surveyor easily observed printed labels for 2 patients (#'s 13 & 33). The labels exposed the patient's names (in capital letters); dates of birth; location; medical record numbers; and physician names. Random observations on 6/28/16 in the CCU revealed Patient #13's printed labels could be seen in the patient's medical record bin, while standing at the nurses station. Review of the hospital policy HIPAA-Patient Privacy Program Requirements, effective date January 2015, revealed Protected Health Information (PHI)...Individually-identifiable health information includes demographic information... Review of the hospital policy HIPAA - Violations/Sanctions, effective date March 2016, revealed Examples of Violations...Improper protection of sensitive information...Leaving records on counters or where otherwise accessible by unauthorized individuals. .
. Based on observations, interview, and policy review the facility failed to ensure the kitchen was maintained and organized in an acceptable manner according to policy and the FDA (US Food and Drug Administration) standards. Specifically, the facility failed to ensure: 1) kitchen floors and equipment were kept clean; 2) sanitized dishes were stored in a clean manner; 3) food processor blades were stored in a clean manner; and 4) a refrigerator containing food items was within an acceptable temperature range. These failed practices placed all patients receiving food from the facility at risk for food borne illnesses and infestation from vermin. Findings: 1) Kitchen Floors and Equipment Random observation throughout the survey on 6/27-30/16 revealed: A small metal trash can under the kitchen sink had a red flaky corrosion on the top and underside of the lid. The sides, inside and out, were splattered with dried debris. Multiple areas on the kitchen floor ,under the refrigerator, and around the floor drains contained a dried buildup of blackened dust, grease, and debris. The outside of all the ovens in the kitchen area had a large amount of built up grease. Observation on 6/27/16 at 2:41 pm revealed the area and equipment located behind the deep fryer was coated in an excessive amount of grease and debris build up. During an interview on 6/27/16 at 2:41 pm the Safety Officer stated the area was covered in grease build up and should have been cleaned. During an interview on 6/30/16 at 9:30 am, the Patient Service Manager (PSM) and the Dietary Director (DD) confirmed the kitchen had an excessive amount of debris and grease build up. Review of the facility policy, AREA AND EQUIPMENT CLEANING FREQUENCY/SCHEDULES, effective date January 2015, revealed there were schedules for daily cleaning of outside of ovens by designated staff. 2) Sanitized Dishes Observation on 6/30/16 at 2:30 pm revealed multiple sanitized trays and pans stacked together. Closer examination revealed the pans and trays were wet and had water dripping off the sides. During an interview on 6/30/16 at 2:30 pm, the PSM stated the dishwasher was supposed to allow the dishware and pans to air-dry before they were stacked together. Review of the facility policy, STORAGE OF POTS, DISHES, FLATWARE, UTENSILS, effective January 2015, revealed: Air dry pots, dishes, flatware and utensils before storage, or store in a self-draining position. Do not stack or store when wet. According to the 2013 FDA Food Code, 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD... 3) Food Processor Blades An observation on 6/30/16 at 2:30 pm revealed several food processor blades were stored in a bin. There was a white powder on and around the blades. Review of the facility policy on 6/30/16 Facility Area and Equipment Cleaning Frequency revealed the blade was to be cleaned after each use. 4) Patient Food Refrigerator Review of the Refrigerator/Freezer Temperature & Cleaning Log, dated June 2016, revealed a refrigerator, located in the Labor and Delivery Nutrition Room (LDNR), had a temperature of 44-47 Degrees F from 6/22-27/16. Further review of the log revealed Temp Range: Food 33-40 [Degrees] F. At the bottom of the log under Discrepancy Log, dated 6/27/16, the box for Plant Ops Notified was marked. Observation in the LDNR, on 6/27/16 at 1:45 pm, revealed a patient food refrigerator contained over 20 8 oz cartons of milk. The refrigerator temperature registered 42 degrees (0) Fahrenheit (F). During an interview on 6/28/16 at 10:35 am, when asked about the process of monitoring of the refrigerator temperatures, the Director of Women & Children's Services stated Night Shift checked the refrigerator temperatures and reported to the charge nurse in the morning if there is any temperature in unacceptable range. During an interview on 6/28/16 at 10:50 am, Charge Nurse #1 stated when she had checked the temperature that morning it was 46 degrees F. The Nurse stated Plant Ops had not come to check the refrigerator yet. According to the FDA food code, Annex 3 page 445, Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature Danger Zone [41o F to 135o F] too long. Review of the facility policy, Refrigerator/Freezer: Storage of Medication & Food, Maintenance, and Proper Cleaning of, effective date August 2014, revealed in PROCEDURE...2) Ensure all refrigerator temperatures are maintained between 38-45 degrees Fahrenheit... .
. Based on interview, record review, and policy review the facility failed to ensure 1 patient's diet was followed. Specifically, the facility failed to ensure a food allergy was listed on the patient's diet card and subsequently served the patient a food she was allergic to. This failed practice created a risk for a severe life threatening allergic reaction. Findings: During an interview on 6/27/16 at 3:20 pm, when asked about the services at the facility, Patient #20 stated there had been a problem on 6/25/16. I had stated that I had corn allergies before on admission. On the dinner menu I requested French fries. When my tray came I found there was a stamped message on the preprinted menu sheet we are very sorry for the substitution and they had sent corn, though I was allergic to corn and corn products. Review of the medical record on 6/27/16 revealed Patient #20 was on a regular diet and was allergic to Corn Containing Products. Review of the Hospitality Suite NCM Select used by dietary to prepare the trays, revealed the corn allergy was not listed. During an interview on 6/28/16 at 9:15 am, when asked about Patient #20 receiving the wrong diet, the Dietary Director stated although the dietary department had a different computer system than the nursing units, the systems should link the patient diets and any food allergies, to the dietary system. The Dietary Director confirmed Patient #20 had received the wrong food because the allergy was not listed in the diet information. During an interview on 6/28/16 at 9:20 am, Dietary Staff (DS) #1 stated In 200 patients one may happen like this [referring to the Patient receiving the food she was allergic to]. DS #1 confirmed the allergy and order had been entered correctly into the system and stated the computer system had not picked up the allergy when the menu was printed. Facility Policy Title,CPCS Diet System & Downtime Procedures Policy, ...effective 2014, revealed The Diet Aide, Supervisor, Dietician will:...Diet Aides check menus with list of current diets prior to each meal. LIST MEAL LABELS is used to identify menu. Stickers are placed on menus for more attention such as FOOD ALLERGY, FLUID RESTRICTION. .
. Based on observation, record review and interview the facility failed to ensure: 1) rubber tops on unopened medication vials were disinfected prior to use; 2) an accurate system for identifying endoscopes was documented in 2 patient records; 3) central line dressings were changed when soiled; 4) handwashing was performed between patients having their blood drawn; 5) patient equipment was cleaned between patients, and 6) staff performed hand hygiene between patients. These failed practices placed patients at risk for illness from infectious diseases. Findings: Medication Vials An observation on 6/27/16 at 11:35 am revealed RN #1 preparing to give medications to Patient #1 prior to her scheduled procedure. During the observation the RN popped the lid off a vial of Versed (medication used to cause sleepiness) and a vial of Fentanyl (opiate pain medication), and without disinfecting the rubber stopper with alcohol, used 2 syringes to withdraw the medication and administered them to the Patient. RN #1 then popped the cap off a vial of Zofran (medication for nausea) and, without disinfecting the rubber stopper, withdrew the medication in a syringe and administered it to the Patient. During an observation on 6/28/16 at 10:29 am, the Certified Registered Nurse Anesthetist (CRNA) prepared to administer medication to Patient #27 prior to her surgery. The CRNA popped the lid off a vial of medication and without disinfecting the rubber stopper, withdrew the contents into a syringe for administration to the Patient. The CRNA then popped the top off of a vial of Propofol (sedative), and without disinfecting the rubber stopper, withdrew the medication into a syringe for use during Patient #27's surgery. During an observation on 6/29/16 at 10:50 am, Scrub Technician #s 1 and 2 popped the plastic top off a vial of lidocaine (a numbing medication), and without disinfecting the rubber stopper, withdrew the medication into a syringe to use during Patient #28's surgery. According to the Centers for Disease Control Prevention, accessed at www.CDC.gov on 7/11/16, Injection Safety Checklist...The rubber septum [stopper] on a medication vial is disinfected with alcohol prior to piercing. Endoscope Documentation During an interview on 6/27/16 at 11:55 am, Endo Technician (ET) #1 explained the process of sterilizing the endoscopes. The ET stated surgical staff provided patient stickers with the last four numbers of the scope on it. Staff taped the sticker to whichever side of the duel sided endoscope washing machine the scope was being washed in. ET #1 showed the Surveyor how the numbers of the scope were manually entered into the endoscope washer's computer. After the process was completed, the scope was dried and a tag was attached to the scope. The slip with the patient's name and the serial numbers of the scope was entered into a log book. Review of the Endoscope log book on 6/27/16, revealed Patient #2 used an endoscope with serial # 41 and with the ID #8540 written on the slip. Patient #3 used an endoscope with serial # 64 with the ID #8119 written on the slip. Review of Patient #2's medical record on 6/28/16 revealed the Patient had an EGD (scope of the upper GI) on 6/27/16 at 10:10 am. The serial number of the instrument used was Colon S/N (serial number) 40. Review of Patient #3's medical record on 6/28/16 revealed the Patient had a scheduled colonoscopy (scope of the lower GI) and polypectomy (removal of polyps) on 6/27/16. The serial number of the instrument used was the Colon S/N 19. When asked about the discrepancy in the numbers, ET #1 stated they were supposed to match but they didn't. Central Line Dressings Observation on 6/27/16 at 2:10 pm revealed large amount of dried blood under the a central line dressing on the right upper arm of Patient #10 Further observation on 6/28/16 at 7:15 am, revealed the same dried bloody dressing present on Patient # 10's right upper arm. Observation on 6/28/16 at 9:45 am revealed a large amount of blood under the central line dressing on the right upper arm of Patient #12 IV Tubing Observation on 6/27/16 at 2:10 pm revealed #10's IV tubing attached to an empty bag of IV fluids was not labeled with a date. Observation on 6/27/16 at 2:45 pm revealed the IV tubing for Patient #34 was not labeled with a date. Review of facility policy Central Line Management dated, 11/22/12, revealed ...Bio-occlusive dressing will be changed...,if the integrity becomes compromised e.g. loose, damp, visibly soiled, bloody...Date and time all dressings and IV tubing. Hand Hygiene Observation on 6/28/16 between 7:10 am and 7:18 am revealed Phlebotomist #1 and a student Phlebotomist drawing blood from the Patients in rooms 331, 332, 333 and 335. The phlebotomist removed gloves after each patient blood draw but did not perform hand hygiene before or after each blood draw on the 4 patients. Patient Equipment and Hand Hygiene An observation in Cardiac Rehabilitation on 6/30/16 at 8:50 am revealed, RN #3 checking patient blood pressures using a stethoscope and blood pressure cuff. The RN moved from patient to patient, in the group of patients attending the class, checking blood pressure readings without cleaning the stethoscope or blood pressure cuff between the patients. RN #3 then handed the blood pressure cuff and stethoscope to the Physical Therapist (PT) without cleaning the equipment. The PT continued to check blood pressure readings on the remaining patients, again with no cleaning between the patients. Neither the RN nor the PT washed hands between patients. Further observation on 6/30/16 at 9:30 am revealed class participants using and moving between various pieces of exercise equipment including; treadmills, hand bikes, floor mats and various weights without any cleaning of the equipment between patients. During an interview on 6/30/16 at 9:00 am RN #3 stated she only cleaned the equipment in the morning before the patients come for exercise, not between each patient using the equipment. During an interview on 6/30/16 at 10:00 am the Director of Rehab stated equipment cleaning should be done between patients. .
. Based on observation the facility failed to ensure signage informing patients of the Emergency Medical Treatment and Labor Act (EMTALA) was posted at all entrances to the Emergency Department (ED) and in the ED treatment areas. These failed practices denied patients access to information about their right to a Medical Screening Exam. Findings: Random observations from 6/27-30/16 of the Emergency Department revealed no EMTALA signage when entering the ED from the ambulance bay. Observations also revealed no EMTALA signage in the exam and treatment areas of the ED. During an interview on 6/30/16 the Charge Nurse #2 confirmed there was no EMTALA signage in the ambulance bay entrance and in the exam and treatment areas of the ED. Review of the hospital policy EMTALA - Signage, dated March 2014, revealed ...Signage must be conspicuously posted in any place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment... .
Based on interview and record review the facility 1) failed to ensure their QAPI (Quality Assessment and Performance Improvement) program monitored implementation of an action plan that had been developed following a sentinel event (an unexpected occurrence involving the risk of, or actual death, or serious physical or psychological injury) for 1 patient (#1), and 2) failed to ensure a root cause analysis (RCA) that had been started for an adverse event (identified as a near miss) for 1 patient (#11) was completed. Not ensuring sentinel events and near misses were investigated, performance improvements implemented, and the process was reevaluated for effectiveness, placed other patients at risk for experiencing similar adverse events. Findings: Patient #1 Record review on 9/4-6/12 revealed Patient # 1 received surgical services at the facility on 1/31/12. The Patient subsequently experienced increased pain and developed an infection at the surgical site. Follow up with the Patient's physician revealed a surgical sponge had been left inside the Patient during the surgical procedure. Review of the QAPI documentation revealed the facility had identified Patient #1's event as a sentinel event and had initiated a root casual analysis (RCA), to determine the cause of the event and develop a plan to mitigate the risk of future reoccurrence. Review of the RCA's Risk Reduction Strategies revealed the facility was to Review count policy with staff quarterly, Incorporate a demonstration, and reinforce expectations to comply with policy, and Revise policy to state that count bags [a sponge containment system used for counting sponges in the operating room] will be used on all procedures. There was no information in the action plan about how the effectiveness of the interventions would be monitored. Review of the facility's policy Count-Sponges, Sharps [and] Instruments, effective date 3/2010, revealed it had not been revised as outlined in the RCA. It had not been updated to include the use of count bags. Review of the documentation for Sponge, Sharps [and] Instrument Counts inservice provided to operating room (OR) staff on 4/4/12, revealed the original, unrevised policy was attached. During an interview on 9/4/12 at 1:15 pm, when asked how the interventions were monitored, both the OR Director and Assistant OR Director replied they had monitored the sponge counts in the OR for 3 months. On 9/5/12 documentation of the sponge count monitoring was requested from the QAPI Director. During an interview on 9/6/12 at 8:30 am, the QAPI Director stated there was no documentation that monitoring had been completed. In addition, she disclosed there was no documentation that any follow up staff education on sponge counts was completed 3 months later. During a second interview on 9/6/12, at 9:10 am, the QAPI Director confirmed the revisions to the policy, to include use of bags for counting, had not been completed. Patient #11 Review of the facility's event log for near misses on 9/4-6/12 revealed that on 3/12/12 a tourniquet had been discovered on Patient #11's left arm after 30 minutes in the post-anesthesia care unit. Further review of the log revealed the section to write the date the action plan was completed was blank. Review of the documentation attached to the event log revealed an RCA meeting was held on 6/26/12, over 3 months after the event. Further review revealed No action plan as of 8/31/12, over 5 months after the event. During an interview on 9/6/12 at 8:30 am, the QAPI Director was asked about the RCA. The Director confirmed that, although it was the facility's policy to complete RCAs on near miss events, this RCA was not complete. Review of the facility's policy Sentinel Event/Root Cause Analysis, effective date 9/2011, revealed Criteria for acceptable action plan includes identification of how the effectiveness of the actions(s) will be evaluated.
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