**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on medical record review of inpatient and outpatient medical records, interview and policy review, it is determined that informed consent documents for 5 out of 30 inpatient and 2 outpatients were not properly executed for procedures or treatments . (Patient identifiers are #14, #15, #16, #17, #18, #24 and #29).
Medical record review on 5/2/16 revealed that Patient #14 was admitted on [DATE] with shortness of breath. Patient #14 arrived in the emergency department with the spouse. The spouse proceed to sign and acknowledge the Conditions of Admission and Consent For Outpatient Care on 5/1/16 at 2112. The Emergency Department practitioner notes alert and oriented X3. Plans to admit. No activated Durable Power of Attorney noted in medical record.
Medical record review on 5/2/16 revealed that Patient #15 was admitted on [DATE] with shortness of breath. Patient #14 arrived in the emergency department with the spouse. The spouse proceed to sign and acknowledge the Conditions of Admission and Consent For Outpatient Care on 4/26/16 at 1255. The spouse does not indicate the relationship to Patient #15. The Emergency Department practitioner notes alert. Plans to admit. No activated Durable Power of Attorney noted in medical record. Case manager note on 4/27/16 revealed that Patient #15 was alert and oriented.
Medical record review on 5/3/16 revealed that Patient #16 was directly admitted on [DATE] with a Subdural Hematoma from a local hospital. Patient #16 was unable to sign the Conditions of Admission and Consent For Outpatient Care on the day of admission. On 5/2/16 the admission office was having Patient #16 sign the An Important Message from Medicare About your Rights but did not have Patient #16 sign the Conditions of Admission and Consent For Outpatient Care.
Medical record review on 5/3/16 revealed that Patient #17 was admitted on [DATE] with a Hangman's fracture. Patient #17 was unable to sign the Conditions of Admission and Consent For Outpatient Care on the day of admission. On 5/2/16 the admission office was having Patient #17 sign the An Important Message from Medicare About your Rights but did not have Patient #17 sign the Conditions of Admission and Consent For Outpatient Care.
Medical record review on 5/4/16 revealed that Patient #18 was admitted on [DATE] with a diagnosis of jaundice. Patient #18 was unable to sign the Conditions of Admission and Consent For Outpatient Care on the day of admission. Patient #18's relative signed without circling the relationship on the Conditions of Admission and Consent For Outpatient Care.
Reviewing the Procedure for Registration Forms and Signatures Policy on 5/4/16 revealed on page 5, C. Patient unable to sign, no Power of Attorney for Healthcare, Legal Guardian and legally authorized/legally empowered individual is present, but other family is present. There may be situations where the registrar recognizes the patient's inability to sign and a family member such as a spouse, mother, father or an adult child of a patient is available to sign on the patient's behalf and a legally authorized individual is not available. State regulations may vary significantly.... The family member representative signing the consent form must indicate their relationship to the patient by circling or writing it on the consent in the space provided.
Interview with Staff B (Patient Access Director ) on 5/3/16 indicated that the Admission personnel would not know if the Conditions of Admission and Consent For Outpatient Care was completed correctly when staff would come to get the An Important Message from Medicare About your Rights the next day. Since the Conditions of Admission and Consent For Outpatient Care form follows you from the start of your emergency room admission to your inpatient stay.
Interview with Staff A (RN/QA) on 5/3/16 indicated that floor staff can not see the Conditions of Admission and Consent For Outpatient Care form as it is contained within a different computer system/program. Staff A confirmed the above findings.
Record review of a sample of 20 outpatient records, selected to sample the Sleep Clinic, Outpatient Rehabilitation, Infusion center, Partial hospitalization program, and Wound Clinic revealed that 2 of these 20 records had incomplete consents or acknowledgments of rights.
Patient #24 signed a Conditions of Admission and Consent For Outpatient Care but the signature was not dated or timed. Also, this patient's record contained a form for the patient to acknowledge that they have received a copy of the Patient's Rights.... and have been given an opportunity to ask any questions .... This document is signed and dated by staff but lacks any Patient or Guardian (if needed) signature.
Review of the record for Patient #29 revealed a Conditions of Admission and Consent For Outpatient Care form was signed by the patient's representative, but the signature was not dated or timed.
Violation Name: SAFETY FOR PATIENTS AND PERSONNEL(A-0536)
Based on record review and interview, the hospital failed to routinely inspect personal shielding to ensure it is properly maintained for safety.
Review of the hospital's Radiology Lead Shield Protection Survey log revealed that 27 of 185 lead shield protective devices had no result documented for being checked in 2015 or 2016 to date for integrity.
Review of the hospital's policy titled 585 Safety - Protective Devices Quality Assurance, dated 3/2006, revealed that Protective Devices will undergo inspection at least annually for defects.
Interview in Staff C (Director of Radiology) on 5/3/16 at approximately 2:30 p.m. confirmed the above findings and revealed the 27 pieces of lead shielding had not been checked for integrity since January of 2015. Interview also revealed Staff C was unsure of the location of the 27 pieces of lead shielding that had not been checked.
Based on interview, observation, and record review, the hospital failed to implement measures for infection control prevention for isolation procedures, kitchen sanitation, and environment.
During tour of the Emergency Department (ED) on 5/2/16 at 12:05 p.m., it was observed that Room 5 was posted with droplet precautions. Staff D (Staff Emergency Medical Technician) wheeled out the Electrocardiogram (EKG) machine cart, removed gloves, wheeled the EKG machine cart to the door of Room 20, cleaned hands with hand rub, and entered Room 20 with the EKG machine cart. Staff D did not sanitize the cart before entering room 20. During interview on 5/3/16 at approximately 12:30 p.m., Staff F (Infection Control Officer) stated to the surveyor that patient equipment must be disinfected between patient use.
During tour of the Cardiac Catheterization Laboratory Suites on 5/3/16 at 11:00 a.m., Room 2 was observed to have several pitted areas in the floor and the countertops had pieces of laminate missing on a corner (facing the entrance of the room), exposing the bare wood. Room 3 was observed to have several pitted areas in the floor and the operating table had a tear approximately an inch and a half in length in the mattress. The paint on the fluoroscope base paint was chipped in several places and the exposed areas were rusted.
During tour of Outpatient Rehabilitation Services physical therapy room on 5/3/16 at 12:45 p.m., a tear approximately 4 inches in length was observed on top of a therapy table. Interview with Staff E(Outpatient Rehabilitation Manager) during tour confirmed the above finding.
Review of the water testing report for April 2015 on Reverse Osmosis (RO) system # 02 revealed a colony count of 54.0 Colony Forming Units per milliliter (CFU/mL) on 4/7/15. The water was not retested until 5/4/15. Review of the water testing report for August 2015 on RO system # 02 revealed a colony count result of 38.0 CFU/mL on 8/14/15. The water was not retested until 8/28/15. Interview with Staff F (Infection Control Officer) on 5/4/16 at 11:00 a.m. confirmed the above finding and revealed that it was policy to repeat testing within 7-10 days when colony counts were above the action level of 20 CFU/mL. Interview with Staff F also revealed that RO system # 02 was used to dialyze patients during the above time periods.
Observation during morning tour in the main kitchen on 5/2/16 revealed Staff G, (Dishwasher), operating the dishwashing machine, wearing gloves while spraying and prepping dirty dishware to be fed into the dish machine, and then while wearing the same gloves, moving over to the clean side of the dish machine and handling the clean dishware coming out. Staff G was observed removing pans exiting the clean side of the dish machine with water pooled in them, turn them upside down and stack them, wet, on top of other clean pans on a nearby rack, without allowing water a chance to dry prior to stacking.
This observation was made while Staff H, (Executive Chef), was also observing and Staff H related that Staff G should change gloves before going to clean from dirty, and wash hands with glove change.
Also observed during the 5/2/16 morning tour of the kitchen was an adjacent equipment storage room, in which there was cookware on a rack that Staff H related was ready to use. Crumbs were observed in a large chafing dish that was positioned uncovered open side up, and crumbs were also observed on a tray, both items were stored on the rack.
Violation Name: ORDERS FOR OUTPATIENT SERVICES(A-1080)
Based on record review and interview, it was determined that the facility's policy for non-staff practitioners ordering outpatient services was not adopted by the medical staff.
During interview on survey, with Staff J (VP of Quality), documentation was requested to show that the medical staff had adopted a policy that addresses practitioners without staff privileges ordering outpatient services. The Patient Access Policy for Procedure for Registration to Undefined Providers was provided. Review of this policy reveals its effective date is 01/01/2014, and it relates, in part The procedures to permit services to be ordered by all provider types are set forth in the facility Medical Staff Bylaws or Rules and Regulations.... No other documentation was presented during survey to establish that the medical staff had either adopted or approved this policy prior to 5/3/16 (see below).
On 5/3/16 the facility provided copies of the Medical Executive Committee minutes for 5/3/16 which revealed that it was unanimously voted to recommend approval for the above existing policy. The minutes also related: Members would like to bring policy back to next meeting for further discussion.