CMS Report and Parkland Action Plan

8/6/2019 CMS Report and Parkland Action Plan

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(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION

(X3) DATE SURVEYCOMPLETED

PRINTED: 08/09/2011FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

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DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

450015 07/21/2011

DALLAS, TX 75235

STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

PARKLAND HEALTH AND HOSPITAL SYSTEM5201 HARRY HINES BLVD

PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY)

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IDPREFIX

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SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY

OR LSC IDENTIFYING INFORMATION)

A 505 Continued From page 53 A 505intravenous injection 1000 cc, expired 6/11 locatedin the crash box. These findings were confirmed inan interview with facility staff I.1 and I.7 on 7/13/11at 3:00 PM.

The facility policy entitled Pharmacy ServicesManual, Inspection of Medication Storage Areasstates that "Each inspection shall be a mechanism

for assuring the following: "5. That no out-datedmedications are present. Out-of-date medicationsshall be removed from stock and returned to theBulk Storage Area."

A 724 482.41(c)(2) FACILITIES, SUPPLIES, EQUIPMENTMAINTENANCE

Facilities, supplies, and equipment must bemaintained to ensure an acceptable level of safetyand quality.

This STANDARD is not met as evidenced by:

A 724

Based on observation and interviews with facility

personnel, the facility failed to ensure that: A)supplies were safely maintained, in that, expiredsupplies were available for patient use in 7 of 21areas, and B) equipment was not safely maintained,in that, there were either expired, or no safetychecks of equipment used by, or for patients in 5 of 21 areas surveyed regarding these requirements.

Findings Included:

A) On tours of the facility and selected outpatientclinics on 07/12/11, 07/13/11, 07/14/11 and07/20/11, the surveyors observed the followingexpired supplies in patient care areas, available for

patient use :

ORM CMS-2567(02-99) Previous Versions Obsolete 4ZNQ11Event ID: Facility ID: 810008 If continuation sheet Page 54 of 150

medication storage areas for theHOMES program. Ongoing analysisand interpretation of audit resultwill be completed by theInterdisciplinary Medication Teamto identify ongoing opportunitiesfor improvement, achievement oftarget, and continuingsustainability of achievement.

A. Supply ManagementCorrective Action/Policies &ProceduresBeginning 7/25 through 8/8/11,Materials Resource Distribution(MRD) staff, in coordination withthe clinical Unit Managers,conducted a thorough inspection ofsupplies being used in clinicalareas to ensure their currency.This inspection included thesupply ordering locations as wellas any other areas where supplieswere stored such as drawers,cabinets, patient rooms, procedurecarts, etc. Areas inspectedincluded: Labor & Delivery West -7/25/11-7/29/11 Neonatal Intensive Care Unit 3rdfloor 302 Sub-Station - 7/25-29/11 HOMES vans - 8/5/11 Pediatric Primary Care Center -8/5/11


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A 724 Continued From page 55 A 724

These findings were confirmed in an interview withPersonnel #I 1 and #I 7 on 07/13/11 at 10:30 AM.

Homeless Outreach Medical Services (HOMES):Mobile Clinic # PH014:

71 - blood collection sets, expired 04/11, located in

a drawer in the nursing station.1 - skin staple extractor, expired 05/10, located ina cabinet in an exam room.These findings were confirmed in an interview withPersonnel #I 1 and #I 7 on 07/13/11 at3:00 PM.

Pediatric Primary Care Clinic:Outpatient:

9 - packages of 4-0 Monocryl sutures, expired07/04, located in the supply room.10 - packages of lubricating jelly, expired 05/11,

located in a cabinet in exam room # 3.

2 - sterile cotton tipped applicators, expired06/11, located in a cabinet in exam room # 6. Thesefindings were confirmed in an interview withPersonnel #K 9 and #K 10 on 07/14/11 at 9:30 AM.

Nursing Unit, 7 South:Inpatient:

9 - neonatal/adult oxygen sensors, expired 12/10,located in a cart in the supply room.These findings were confirmed in an interview withPersonnel #N 10 and #N 14 on07/20/11 at 2:00 PM.


On 8/23/11, an additionalmodification is being executed inthe Point of Use Storage System(PYXIS) to further ensure properrotation of stock and removal ofexpired stock. This modificationincludes use of an OutdateManagement Function electronicnotification regarding outdatedsupplies. Item expiration datesare also being updated during

resupply of PYXIS units. MRDstaff education regarding thesePYXIS actions began on 8/15/11 andwas completed on 8/18/11.

The hospital is in the process ofimplementing a Medical ManagementBar Coding System to furtherenhance the hospitalscapabilities for effectively andsafely managing supplies.

Compliance MonitoringThe MRD Leadership Team beganconducting monthly audits throughuse of direct observations in thefollowing locations: Labor &Delivery West and NeonatalIntensive Care Unit. HOMESProgram and Pediatric Primary CareCenter are also conducting similaraudits.

These audits consist ofobservations of supply storagelocations as well as any otherareas where supplies are storedsuch as drawers, cabinets, patientrooms, procedure carts, etc.Results of audits are reported toand reviewed by the Director ofMRD monthly with action taken whennecessary.


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A 724 Continued From page 56 A 724 All of the above expired supplies were found inpatient care areas, and were available for patientuse.

B) On tours of the facility 07/12/11, 07/14/11 and07/18/11 the surveyors observed the followingequipment used by or for patients, had not beenchecked for safety, or their safety checks had

expired.

Labor & Delivery, 3 West:Triage:

1 - fetal monitor, expired 06/11.In an interview at 10:30 AM on 07/12/11 withPersonnel #B 9, she verified this expiredequipment check in Triage.

Triage Overflow:

1 - electric patient bed, had no equipment checks.1 - electric lamp, used for patients, had no

equipment checks.In an interview at 10:45 AM on 07/12/11 withPersonnel #B 8, she verified there wereno safety checks on the equipment identified inTriage Overflow.

Labor & Delivery, 3 East:Room # LDR 8:

1 - electric patient bed, equipment check expired02/11.In an interview at 10:45 AM on 07/12/11 withPersonnel #B 8, she verified the expired equipmentcheck in Room # LDR 8.


Metric measured: Number ofsupplies expired per each separateclinical location (Labor &Delivery West and NeonatalIntensive Care Unit, and COPCs /HOMES). Target for achievement:Zero Expired Supplies per Area.

Results of the monthly audits arepresented at the time of theobservation to the areas NurseManager for immediate action incases of lack of adherence toprocedure. Aggregated results arepresented to Nurse OperationsCouncil (NOC) on a monthly basis.

Analysis and interpretation ofaudit results are completed by theMRD Leadership Team and the NOCLeadership to identify ongoingopportunities for improvement,achievement of target, andcontinuing sustainability ofachievement.B. Equipment Maintenance

As an immediate response, theFacility Support Service (FSS)Department conducted equipmentsafety checks or removed theequipment from service at the timethe deficiencies were identified.The following immediate and followup actions were taken regardingspecific survey observations:

FETAL MONITOR - Labor & DeliveryWest, and Triage areas: The fetalmonitor unit was replaced by theClinical Engineering Department on7/29/11. An email was sent on


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A 724 Continued From page 57 A 724Inpatient Rehabilitation Unit, 8 East:Physical Therapy Gym:

3 - electric platform exercise mats, had noequipment checks.In an interview at 3:00 PM on 07/14/11 withPersonnel #B 25, and also an interview atapproximately 3:00 PM on 07/18/11 with Personnel

#B 37, they verified there had been no safetychecks performed on the Inpatient electric platformexercise mats.

Simmons Ambulatory Surgery Center:Medication Area:

1 - Medication refrigerator, equipment check expired12/10.In an interview at 11:00 AM on 07/18/11 withPersonnel #B 40, he verified the expiredequipment safety check for this medicationrefrigerator.

The above individual interviews each confirmed thatall equipment cited was used in conjunction withdirect patient care, and that their safety checks hadnot been maintained.

A 747 482.42 INFECTION CONTROL

The hospital must provide a sanitary environment toavoid sources and transmission of infections andcommunicable diseases. There must be an activeprogram for the prevention, control, andinvestigation of infections and communicablediseases.

This CONDITION is not met as evidenced by:

A 747

Based on observation, interview, and recordreview, the hospital did not ensure that the


8/16/11 to nursing leadershipcommunicating the importance offollowing the hospital policy onchecking for current preventivemaintenance labels on medicalequipment and reporting out ofdate equipment to the ClinicalEngineering Department. Inaddition, the Clinical EngineeringDepartment conducts equipmentrounds at least twice weekly for

equipment that is due forpreventive maintenance.

ELECTRICAL SAFETY CHECKS -Triage Overflow: Bed maintenancechecks were completed 7/12/11.FSS Department staff verified thatthe involved bed is included inthe hospital asset inventory. Theelectrical lamp does not requirean equipment check per UtilityManagement Policy #807-07-02. Ifthe lamp needs repair, a safetycheck is performed and documentedas completed before being placedback in service. ELECTRICAL SAFETY CHECKS -Inpatient Rehabilitation Unit, 8East, Physical Therapy Gym:Electric platform exercise matchecks were performed on 7/14/2011Continued on page 58A


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A 747



PAGE 58 A

Continued from page 57and properly labeled. FSSDepartment staff verified that theplatform exercise mats areincluded in the hospital assetinventory.

BED INSPECTION - Labor &Delivery East, Room # LDR 8: Theinvolved patient bed was locatedand Preventive Maintenance checkwas completed on 7/12/11. FSSDepartment staff verified that theinvolved bed is included in thehospital asset inventory.

REFRIGERATOR INSPECTION -Simmons Ambulatory Surgery Center(ASC), Medication refrigerator.FSS staff verified that aquarterly Preventive MaintenanceCheck is being generated from theComputerized MaintenanceManagement System (CMMS). Theinvolved Unit was placed inservice and re-entered back intothe refrigeration monitoringsystem. There was no indicationthat the unit fell out of theappropriate temperature range.Preventive maintenance checksremain active for this unit.

Continued on page 58B


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A 747



PAGE 58 B

Continued from page 58 A

All medication refrigerators areplaced on a quarterly preventivemaintenance program. The units arealso tied into electronictemperature monitoring systems.The FSS Department will verifymedication refrigerators are inservice at the time a preventivemaintenance is generated. Any

unused units will have preventivemaintenance and checked againbefore being placed in service.

Educational EffortsThe FSS staff were educated onFacilities Support ServicesProcedure Preventive maintenanceGeneral Instructions regardingpreventive maintenance on 8/19/11.

All electric beds have been addedto the main hospital inventory.Currently, the FSS Department isresponsible for inspecting all thehospitals clinical areas andstorage areas to verify that allbeds in service are up to date

Continued on page 58 C


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A 747



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Continued from 58 cwith preventive maintenance.Effective 10/1/11, a servicecontract has been approved tocomplete all preventivemaintenance services for thehospitals beds. This servicecontract will be managed by theClinical Engineering Department.

Compliance Monitoring

The Director of ClinicalEngineering and the Director ofFSS are working with thePurchasing Department to establisha process for the registration ofnew equipment that will ensureinclusion of this equipment in thehospital asset management database and the ComputerizedMaintenance Management System(CMSS) for scheduling of routinepreventive maintenance


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A 747 Continued From page 58 A 747infection control policies were implemented andenforced. Infection control practices were notadhered to by physicians, nursing staff, and other personnel, for 7 of 14 departments and/or services(Peri-operative Services, GI Lab [GastrointestinalLaboratory], Cardiac Lab, Ambulatory SurgeryServices, Renal Dialysis, Perinatal Services and theEmergency Department [ED]).

It was determined this deficient practice created anImmediate Jeopardy situation and placed patients atrisk of severe infection and possibly subsequentdeath.

Findings Included:

1. Numerous staff wore used masks hanging downfrom their necks while walking in the hallway or other non-surgical/treatment areas.

2. Numerous staff members did not dispose of their soiled gloves and wash their hands after

treating patients and touching patient equipment.

3. A disposable jacket was hanging in thesterilization area. Personnel food items weresitting in the patient treatment areas.

4. Infectious waste, including used syringes, bodyfluids, used respiratory equipment and used suctionequipment were not disposed of properly in patientrooms/cubicles.

5. Personnel did not remove their gloves and washtheir hands after drawing blood work then touchingthe surface of equipment thus contaminating the

equipment.



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6. ED bed was not cleaned with disinfectantbetween patient use.

7. All ED rooms located in the Main ED contained ayankauer suction tip in an open package that wasattached to the suction canister and available for patient use. The open yankauer suction tips are not

discarded between each patient after patients aredischarged.

8. Environmental Services Technician's did notproperly transport waste. The waste carts wereoverfilled with trash bags and not covered duringtransport through the patient care area of the ED.

Cross Refer: Tag A0749

A 749 482.42(a)(1) INFECTION CONTROL OFFICERRESPONSIBILITIES

The infection control officer or officers must develop

a system for identifying, reporting, investigating, andcontrolling infections and communicable diseases of patients and personnel.


A 749

Based on observation, interview, and recordreview, the hospital did not ensure that the infectioncontrol policies were implemented and enforced.Infection control practices were not adhered to byphysicians, nursing staff, and other personnel, citing7 of 14 departments and/or services (Peri-operativeServices, GI Lab [Gastrointestinal Laboratory],Cardiac Lab, Ambulatory Surgery Services, RenalDialysis, Perinatal Services and the EmergencyDepartment [ED]). The following poor infection



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A 749 Continued From page 60 A 749control practices were observed:

1. Numerous staff wore used masks hanging downfrom their necks while walking in the hallway or other non-surgical/treatment areas (Physician #C4,#C5, #C6, #C7, #C9, Personnel #C30 and #C37).

2. Numerous staff members did not dispose of

their soiled gloves and wash their hands after treating patients and touching patient equipment(Personnel #B12, #C10, #C12, #C31, #C33, #C34,#C36, and #C38).

3. A disposable jacket was hanging in thesterilization area. Personnel food items weresitting in the patient treatment areas.

4. Infectious waste, including used syringes, bodyfluids, used respiratory equipment and used suctionequipment were not disposed of properly in 4 of 4ED patient rooms/cubicles (Room 3, Cubicle 10,Room 19, and Cubicle 39).

5. One of 1 ED personnel (Personnel #39) wasobserved not removing his gloves and washing hishands after drawing blood work then touching thesurface of equipment thus contaminating theequipment.

6. One of 1 ED bed (SWAT Bed in Main West) wasnot cleaned with disinfectant between patient use.

7. All ED rooms located in the Main ED contained ayankauer suction tip in an open package that wasattached to the suction canister and available for patient use. The open yankauer suction tips



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A 749 Continued From page 61 A 749are not discarded between each patient after patients are discharged.

8. Two of 2 Environmental Services Technician's(EVS Techs, Personnel #14 and Personnel #37) didnot properly transport waste. The waste carts wereoverfilled with trash bags and not covered duringtransport through the patient care area of the ED.

Findings Included:

1) On a tour on 07/12/11 at approximately 10:40 AM, 1:35 PM, & 2:10 PM with Personnel #C2, thesurveyor observed in the main hallway of the 2ndfloor (Surgery Department/ Perioperative Services)the following physicians with used masks hangingdown from their necks: Physician #C4, #C5, #C6,#C7, & #C9.

In an interview on 07/12/11 at approximately 2:15PM, Personnel #C1 was informed of the abovefindings and was asked what the hospital's PPE

(Personal Protective Equipment) protocol was,specifically the wearing of the mask. Personnel#C1 stated that the hospital abides the"Perioperative Standards and RecommendedPractices." Personnel #C1 stated that the maskshould cover the mouth and nose in a securedmanner, the mask should not be worn hangingdown from the neck, and the mask should not beworn outside the operating room.

The "Perioperative Standards and RecommendedPractices 2011 Edition" printed by the hospital'scommand center on 07/14/11 required "VI.a. Themask should cover the mouth and nose and be

secured in a manner to prevent



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A 749 Continued From page 62 A 749venting. VI.b.1. Masks should not be worn hangingdown from the neck...the filter portion...harborsbacteria collected from the nasopharyngealairway...VI.c. Surgical masks should be discardedafter each procedure."

2) On 07/13/11 at approximately 9:15 AM, thesurveyor with Personnel C#2 conducted a tour of

the hospital's GI Lab. At 10:25 AM, the surveyor observed Patient #C6 undergoing an EGDprocedure (Esophagogastroduodenoscopy) in GIroom #1. The surveyor observed Personnel #C10administering conscious sedation medication at10:26 AM, 10:28 AM, and at 10:30 AM. Personnel#C10 did not wear gloves when administering themedications. Personnel #C10 did not wash her hands or apply alcohol rub during these directpatient care tasks.

On 07/13/11 at 10:43 AM, the surveyor withPersonnel #C2 went to GI room #3 to observePatient #C9's colonoscopy procedure. At 10:45

AM, the surveyor observed Personnel #C12, withoutgloves, administered conscious sedation medicationto the patient. At 10:50 AM, Personnel #C12,without gloves, administered conscious sedationmedication to the patient. At 10:51 AM, Personnel#C12 put on a pair of clean gloves and adjusted thepatient's nasal cannula. At 10:53 AM, Personnel#C12 administered "diphenhydramine" as orderedand walked to the computer station and entereddata. At approximately 10:54 AM, the physicianrequested a towel. Personnel #C12 took off her lefthand glove and obtained a clean towel from acabinet with her left hand and handed it over to thephysician. Personnel #C12 then put on a clean

glove on her left hand. At approximately 10:55



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A 749 Continued From page 63 A 749 AM, Personnel #C36, the GI technician whoassisted Physician #C14 & #C15 took off her soiledgloves. Without washing her hands or applyingalcohol rub, she took a small medicine bottle, with adropper; she then added a few drops to theirrigation water.

Policy # IC 2-00: "Standard Precautions" dated

10/2008 required "Protocol: Standard Precautionsare based on principles that all blood, body fluids,secretions...may contain transmissible infectiousagents...Standard Precautions are also intended toprotect patients by ensuring that healthcarepersonnel do not carry infectious agents to patientson their hands..."

Policy # IC 2-10: Hand Hygiene" dated 03/2010required "Categories of opportunities for proper Hand Hygiene: Before patient contact...Beforeaseptic technique...After patient contact..."

3) On 07/14/11 at approximately 12:35 PM, the

surveyor with Personnel #C2 conducted a tour of the hospital's Cardiac Lab. We were joined by theunit manager, Personnel #C29. The three of usobserved Patient #C11's cardiac catheterizationprocedure in Lab A. The surveyor observedPersonnel #C30 and Personnel #C37 not properlywearing their masks. The lower portions of their masks were tied loosely which allowed venting. Atapproximately 1:50 PM, Personnel #C29 wasinformed of the findings and she stated that themasks should be worn in a secure manner toprevent venting as per hospital policy.

On 07/18/11 at 9:15 AM, the surveyor with

Personnel #C2 conducted a tour of the hospital's



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A 749 Continued From page 64 A 749Cardiac Lab. We were joined by the unit manager,Personnel #C29. The three of us observed Patient#C13's cardiac catheterization procedure in Lab A.

At approximately 9:21 AM, the surveyor observedPersonnel #C31 with her non-sterile gloves touchedthe sterile field twice. At approximately 9:25 AM,Personnel #C29 was informed of the findings andshe stated that Personnel #C31 should not have

touched the sterile field with non-sterile gloves. At9:30 AM, the physician asked for a sterile catheter.Wearing the same gloves she had worn at thebeginning of the procedure, Personnel #C31obtained a pack of sterile catheter, opened thepack, and handed the opened sterile pack for thephysician get the sterile catheter. At 9:33 AM,Personnel #C29 was informed of the findings andwas asked how it was supposed to be done.Personnel #C29 replied that Personnel #C31 shouldhave taken off her soiled gloves and performedhand hygiene prior to obtaining the catheter sterilepack.

4) On 07/18/11 at 10:09 AM, the surveyor withPersonnel #C2 conducted a tour of the hospital'sambulatory surgery center. We were joined byPersonnel #C1 and #C32. At 11:07 AM, the four of us were in the PACU (post-anesthesia care unit).The surveyor observed Personnel #C33 put on apair of clean gloves and proceeded to perform directpatient care. At 11:10 AM, Personnel #C33 tookoff her soiled gloves and proceeded to document inthe patient's chart. She then pulled the blanket tocover the patient's shoulder. Personnel #C33 didnot wash her hands or apply alcohol rub. Atapproximately 11:15 AM, Personnel #C32 wasinformed of the findings and he stated that

Personnel #C33



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A 749 Continued From page 65 A 749should have performed hand hygiene after taking off her gloves.

On 07/18/11 at approximately 11:29 AM, Personnel#C1, #C2, #C32, and the surveyor went to operatingroom #6 to observe Patient #C16's procedure: openreduction internal fixation on the left ankle. At11:30 AM, the surveyor observed Personnel #C38

put on a pair of sterile gloves and started to disinfectthe patient's left lower extremity in preparation for the surgical procedure. At approximately 11:34

AM, Personnel #C38 took off her soiled gloves andrepositioned the patient. She then proceeded tothe tourniquet machine to adjust the pressure asordered by the physician. Personnel #C38 did notwash her hands or apply alcohol rub after taking off her soiled gloves. Personnel #C32 was informedof the findings and stated that Personnel #C38should have performed hand hygiene after taking off her soiled gloves.

On 07/18/11 at 1:26 PM, Personnel #C1, #C2,

#C32, and the surveyor conducted a tour in theambulatory surgery center's sterile processing area.In the clean area where they packaged the cleaninstruments for sterilization, the surveyor observeda disposable jacket hung on the upper left corner of a pegboard containing clean instruments hanging init. Personnel #C20 was asked about thedisposable jacket since it was behind her worktable. Personnel #C20 immediately removed thedisposable jacket and stated it was "clean."Personnel #C32 told the surveyor that thedisposable jacket should not have been hung withthe cleaned instruments.

At 1:40 PM, Personnel #C1, #C2, #C32, and the



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A 749 Continued From page 66 A 749surveyor proceeded to go to the decontaminationroom. The surveyor observed Personnel #C34come in the room. With a gloved hand, she carrieda large deep transparent plastic container thatcontained dirty instruments and/or equipment. Shetransferred the dirty instrument and/or equipment tothe ultrasound cleaning machine. Wearing thesame soiled gloves, she began disinfecting the

large deep transparent plastic container and carriedthe container out of the decontamination room.

At 1:45 PM, Personnel #C32 was informed of thefindings. Personnel #C32 was asked how it wassupposed to be done. Personnel #C32 explainedthat prior to cleaning the container; Personnel #C34should have taken off her soiled gloves andperformed hand hygiene.

5) On 07/19/11, during observation of the dialysisunit on the fifth floor at 10:15 AM, the surveyor observed as the Medical Director, Personnel #O4,for the Acute Dialysis Unit consumed a drink from

an open Styrofoam cup in the patient treatment areaat the nurse's station, while patients in the dialysisunit dialyzed.

In an interview with the supervising nurse and theDirector of the dialysis unit (Personnel #O1 and#O2), on 07/19/11 at 2:00 PM, they confirmed thatstaff members are not allowed to eat or drink in thedialysis unit.

The facility's Acute Dialysis Unit "InfectionPrevention Procedures of the Environment" policyRD 06/11 included the following:"4. Staff members, including physicians, shall not

bring food or drinks into the patient care area."



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On 07/19/11, during observation of the dialysis uniton the fifth floor at 11:04 AM, the surveyor observedas a nurse assigned to a patient receivingapheresis, use gloved hands to pick up a ball fromthe floor. The nurse sanitized the ball, and placedthe ball on the bedside table. The nurse did notremove the contaminated gloves and sanitize her

hands, but instead used the same contaminatedgloves to adjust the bloodlines that connected thepatient to the apheresis machine.

The facility's STANDARD PRECAUTIONS policy IC2-00 10/08 includes the following:"1.B.2.e. Change gloves 1) after handlingcontaminated items."The facility's INFECTION CONTROL HANDHYGIENE PROTOCOL IC2-10 03/10 included thefollowing:"A. Indications for hand antisepsis and handwashing:b. Before patient contact (before entering the area

around the patient that includes the patient's bed,side table, i.v. pole, etc.)h. After removing gloves.i. After contact with the patient environment (itemsaround the patient such as the patient's bed, sidetable, i.v. pole, etc.) if the patient does not havediarrhea or placed in Contact-D isolation."

On 07/19/11 at 11:18 during observation of thedialysis unit on the fifth floor, a nurse was observedentering information into a dialysis machine withoutgloves, with a patient's blood in the blood lines andwhile the patient dialyzed.



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A 749 Continued From page 68 A 749The facility's Acute Dialysis Unit "InfectionPrevention Procedures of the Environment" policyRD 06/11 included the following:

"5. PPE shall be placed in strategic areas in thetreatment room. Disposable gloves shall be wornin all procedures involving contact with bloodproducts, veni-puncture and cleaning equipment."

On 7/20/11, during tour and observation of thedialysis unit on the tenth floor, the unit wasobserved to have a room directly off the patienttreatment area, which had a sink with a pHoenixmeter station adjacent to it. The room wasobserved to have various supplies available for patient use: 2 oxygen tanks, 2 dialysis machines,one portable RO, and various Centrisolconcentrates. The room also included amicrowave, refrigerator, water dispenser, and staff lockers.

(The portable RO machine is water purification

system that is connected to the hemodialysismachine and transported to various locations in theacute hospital setting to dialyze the patient whenthey are not able to be transported to the dialysisunit.)

In an interview with the Unit Director and EquipmentTechnician (Personnel #O5 and #O2), theequipment technician confirmed that some surfacesof the portable RO machine could not be sanitizedafter it had been used for patient treatments andwas contaminated. They also confirmed that themicrowave, refrigerator, and the water dispenser were for staff use.

6) On a tour on 07/12/11 at approximately 1:45



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A 749 Continued From page 69 A 749PM with Personnel #B8, the surveyor observed the"turn-over" cleaning of a recently used DeliveryRoom (OR # 4) located on the 3rd floor (Labor &Delivery Department/ Perinatal Services), wherePersonnel #B12 cleaned from top to bottom aroundthe OR table and then cleaned the dirty step stoolunderneath. Personnel #B12 then changed to aclean cloth before cleaning the infant warmer, but

did not change her gloves between moving from a"dirty" area to a "cleaner" area.

In an interview on 07/12/11 at approximately 2:15PM, Personnel #B11 was informed of the abovefindings, and he agreed that when cleaning medicalequipment in the operating rooms that glovesshould be changed when moving from a "dirty" areato a "cleaner" area, to prevent contamination of the"cleaner" area.

The facility "Infection Control Protocol/ StandardPrecautions" policy IC 2-00, dated 10/08, under B.2(d & e) noted to "remove gloves after contact

with...the surrounding environment (includingmedical equipment) using proper technique," andalso to "change gloves after handling contaminateditems" and "before touching environmental surfacesafter soiling...before touching clean site (movingfrom "dirty to "clean" sites)."

7) During a tour of the ED at 11:10 A.M. on07/11/11, accompanied by Personnel #2, thesurveyor observed infectious waste, including usedsyringes, body fluids, and used respiratoryequipment that were not disposed of properly in thefollowing patient care areas of the department:



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a. Room 3

- The top of the Mayo Stand contained one pair of used gloves, one Endotracheal Tube still inflated,one 10 ml (milliliter) syringe which contained 5 ml of blood, 1 Stylet, 1 used 18 gauge IV catheter andone 5 ml syringe which contained 5 ml of clear fluid.

- The top of the Storage Cart had spots of abrown liquid substance, 1 used yankauer suctiontip, 2 soiled 2x2 sponges, a thermometer and aused 20 ml empty syringe.

- The red biohazard container on the floor hadblood stained linen on top of it.

- The counter had a 1 ml syringe with anuncapped needle attached to the syringe.

Cubicle 10 - Patient #4 was observed in the bed incubicle 10. The oxygen flowmeter had a handheldnebulizer containing clear fluid attached with oxygentubing. The nebulizer and tubing was draped over the flowmeter. The nebulizer was uncovered and

did not have a label with patient identifiers. Patient#4 was asked if he had been given a breathingtreatment. He stated, "No."

Room 19 - The suction canister on the wallcontained approximately 10 ml of clear-pinkish fluid.Suction tubing and a open package containing ayankauer suction tip was attached to suctioncanister by the suction tubing. The room had beencleaned and indicated ready for use for a newpatient.

Cubicle 39 - Patient #5 was observed in the bed incubicle 39. The air flowmeter had a handheld

nebulizer containing clear fluid attached with



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A 749 Continued From page 71 A 749oxygen tubing. The blue colored wide bore tubingwas stuck over the top of the flowmeter with thenebulizer and mouthpiece attached to the oxygentubing. The nebulizer was uncovered and did nothave a label with patient identifiers. Patient #5 wasasked if he had been given a breathing treatment.He stated, "No."

During the observation the Charge RN(Personnel #7) and Personnel #2 verified the abovefindings.

b. RN (Personnel #39) was observed drawingblood for lab work on a patient that was sitting in achair in the West ED hall. After drawing the bloodinto the lab tubes, he did not remove the gloves. Hecarried the lab tubes in his gloved hand over to thecomputer in the hall. He then proceeded to type onthe keyboard off the computer with hiscontaminated gloves. He then placed stickers onthe lab tubes and placed them into a biohazard bag.He then removed his gloves and discarded them in

the waste container. He then applied hand sanitizer and took the biohazard bag to the lab. Personnel #2verified the above findings.

c. The surveyor observed 3 different patientsplaced in the ED SWAT bed (assessment bed)located in the West ED, Pod 1 at the end of theNursing Station. The bed was not cleaned betweeneach patient use. The surveyor observed thecleaning process between patients after they wereexamined by the MD (Personnel #12). RN #9 wasobserved preparing the bed between patients. RN#9 removed the white paper that partially coveredthe middle of the bed mattress and did not clean or

wipe the bed



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A 749 Continued From page 72 A 749mattress down with a disinfectant. He then coveredthe bed with clean white paper between eachpatient. At that time, RN #9 was asked if it ishospital policy to clean the bed mattress with adisinfectant between each patient prior to placinganother patient in the bed. He stated, "Yes." He wasasked if he followed hospital policy. He stated, "No."Personnel #2 also verified the above findings.

d. On 07/11/11 at approximately 10:30 AM thesurveyor observed the ED rooms located in theMain ED contained a yankauer suction tip in anopen package that was attached to the suctioncanister and available for patient use. The openyankauer suction tips were not discarded betweeneach patient after the patients were discharged fromthe rooms. At this time the Charge RN (Personnel#7) was asked if it is hospital policy to clean theroom between each patient and remove any opensupplies and discard them. She stated, "Yes." Shewas asked if it is hospital policy to keep the openyankauer suction tips attached to the suction

canister after each patient had been dischargedfrom the patient room. She stated, "Yes. Thesuction tips are still covered and in the package. Wekeep them attached in case of emergency." Shewas asked if she could verify if the suction tips hadnot been taken out of the package and tamperedwith or used between each patient. She stated,"No." She verified each room in the ED had openpackages of suction tips attached to the suctioncanisters.

e. During a tour of the ED at 10:50 A.M. on07/11/11, the surveyor observed the EnvironmentalServices (EVS) Tech (Personnel



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A 749 Continued From page 73 A 749#37) transporting waste in an uncovered, overfilledwaste cart in the patient care area of the Main ED.The trash bags were stacked approximately 18inches above the top of the waste cart. Personnel#37 was asked if it is hospital policy to transportwaste in the cart when it is overfilled anduncovered. She stated, "Yes. It is in bags."

During a separate tour of the ED at 11:00 AM on07/12/11, the surveyor observed the EVS Tech(Personnel #14) transporting waste in anuncovered, overfilled waste cart in the patient carearea of the Main ED. The trash bags were stackedapproximately 24 inches above the top of the wastecart. Personnel #14 was asked if it is hospital policyto transport waste in the cart when it is overfilledand uncovered. She stated, "Yes, it is ok if it is thishigh (pointed to her upper chest) but no higher thanhere. (She brought her hand up to the level of her eyes.)"

The Infection Control (IC) Protocol entitled

"Standard Precautions" dated 10/08 requires,"Remove gloves after contact with apatient...change gloves...before touchingenvironmental surfaces...Needles andsyringes...must be disposed of in rigid, IC approved,puncture-resistant containers at the point of use...Allblood specimens are handled as if contaminated byplacing in a biohazard labeled bag...Linen: Allcontaminated linen is placed in a yellow nylon bagat point of use...Patient Care Equipment...must bedisinfected or sterilized betweenpatients...Supplies...Supplies which have been in apatient's room...must not be taken back into stock..."



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A1104 Continued From page 81 A1104part of PHHS and is a different provider. He wasasked to review the hospital policy entitled"EMTALA" dated 06/11 and asked if the policyrequires all patients presenting to the ED requestingcare will be given a MSE by a QMP to determine if an EMC exists and provide stabilizing treatmentprior to transferring to another facility. He stated,"Yes." He was then asked if the hospital policy is

following EMTALA rules and regulations in regardsto medically screening and providing an appropriatetransfer for pediatric patients. He stated, "No."

A1160 482.57(b) RESPIRATORY CARE SERVICESPOLICIES

Services must be delivered in accordance withmedical staff directives.


A1160

Based on observation, record review, andinterview, the hospital failed to ensure the

Respiratory Care Department policies andprocedures were followed for infection control andprevention practices in that used respiratoryequipment was not stored properly, labeled withpatient identifiers or disposed of properly in 2 of 2ED patient cubicles (Cubicle 10 and Cubicle 19)where patient's were present.

Findings Included:

During a tour of the ED at 11:10 AM on 07/11/11,accompanied by Personnel #2, the surveyor observed used respiratory equipment that was notstored properly, labeled with patient identifiers or

disposed of properly in the following patient EDrooms/cubicles:



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A1160 Continued From page 82 A1160Cubicle 10 - Patient # 4 was observed in the

bed in cubicle 10. The oxygen flowmeter had ahandheld nebulizer containing clear fluid attachedwith oxygen tubing. The nebulizer and tubing wasdraped over the flowmeter. The nebulizer wasuncovered and did not have a label with patientidentifiers. Patient #4 was asked if he had beengiven a breathing treatment. He stated, "No."

Cubicle 39 - Patient #5 was observed in the bedin cubicle 39. The air flowmeter had a handheldnebulizer containing clear fluid attached with oxygentubing. The blue colored wide bore tubing was stuckover the top of the flowmeter with the nebulizer andmouthpiece attached to the oxygen tubing. Thenebulizer was uncovered and did not have a labelwith patient identifiers. Patient #5 was asked if hadbeen given a breathing treatment. He stated, "No."

During the observations the Charge RN(Personnel #7) and Personnel #2 verified the abovefindings.

The Respiratory Care Department Policy entitled"Processing and Sterilization of RespiratoryEquipment" dated 06/11 requires, "Small volumemedication nebulizers...Hand-held...Discard after patient use...Discontinuing equipment. Stripdisposable supplies from equipment and discard inthe appropriate bag/container in area. Placepermanent equipment in clear plastic bag...labelwith a sticker indicating "Soiled" and return todepartment..."

The Respiratory Care Department Policy entitled"Disposable Equipment Changes" dated 06/11

requires, "To reduce the risk from nosocomial



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A2402 Continued From page 89 A2402Required: Each department that providesemergency services shall post a sign (English andSpanish) in a place or places likely to be noticed byall individuals entering the department..."

In an interview at 11:05 AM on 07/11/11, the EDNurse Supervisor (Personnel #7) confirmed theabove findings.

A2404 489.20(r)(2) and 489.24(j)(1-2) ON CALLPHYSICIANS

489.20(r)(2)[The hospital (including both the transferring andreceiving hospitals), must maintain] a list of physicians who are on call for duty after the initialexamination to provide further evaluation and/or treatment necessary to stabilize an individual withan emergency medical condition.

489.24(j)(1)Each hospital must maintain an on-call list of physicians on its medical staff in a manner that bestmeets the needs of the hospital's patients who arereceiving services required under this section inaccordance with the resources available to thehospital, including the availability of on-callphysicians.

489.24(j)(2)(i)The hospital must have written policies andprocedures in place to respond to situations inwhich a particular specialty is not available or theon-call physician cannot respond because of circumstances beyond the physician's control.

489.24(j)(2)(ii)The hospital must have written policies and

A2404


1. Background:EMTALA related requirements

permit hospitals to maintain anon-call list in a manner that bestmeets the needs of its patientsreceiving services required underEMTALA. To ensure that on-callscheduling is continually up todate and always readily availableto staff, for the past five plusyears Parkland has utilized astate of the art on-line directoryand on-call system. This systemprovides enhanced technologynecessary to rapidly locate anon-call provider via pager orcellular phone in a manner that ismore efficient and effective thantraditional manually dialedtelephone contact. The purpose ofimplementing the system was toprovide enhanced patient safety byproviding real time updatedcontact information (e.g. in theevent of a broken or lost pager,the system is simultaneouslyupdated as new pager is issued,rather than reflecting outdatedinformation that delays contact).


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A2404 Continued From page 90 A2404procedures in place to provide that emergencyservices are available to meet the needs of patientswith emergency medical conditions if it elects topermit on-call physicians to schedule electivesurgery during the time that they are on call or topermit on-call physicians to have simultaneouson-call duties.

This STANDARD is not met as evidenced by:Based on observation, record review and interview,

the hospital:

1. Did not maintain an adequate on-call list of specialty physicians and their alternates who arecurrent members of the medical staff or who havehospital privileges with telephone numbers or accurate contact information for 8 of 8 (ApheresisConsult, Burn Consult, Cardiovascular ThoracicSurgery, Drug and Alcohol Emergency ServicesDepartment (ESD) Consult, Drug and AlcoholPatient Consult, Emergency General SurgeryConsult, Gynecology (GYN) Consult, and Obstetrics(OB) Consult) medical specialties provided by thehospital from 06/01/11 - 06/30/11.

2. The on-call list did not contain the individualphysician names who were on call in 3 of 8specialties (Apheresis Consult, Drug and AlcoholESD Consult, and Drug and Alcohol PatientConsult) from 06/01/11 - 06/30/11.

3. The on-call schedule reflected Medical Residentswho were on call for hospital specialty services thatare not current members of the medical staff and donot have hospital privileges as required by thehospital Medical Staff in 5 of 8 (Burn Consult,Cardiovascular Thoracic Surgery Consult,Emergency General Surgery Consult,


The on-line directory is readilyavailable to the ED staff andincludes both physician andnon-physician call lists. It iseasily and readily accessible fromany computer in the hospital. Inthe unusual circumstance that theon-call system technology is notfunctioning, hospital operatorshave immediate access to currentcontact information for each

individual provider and can pagethe provider.On-call provider contactinformation is centralized withinthe on-call database. Access tovisualize the telephone number islimited to designated staff, suchas the Parkland Page Operators toavoid mistaken manual dialing. Thenurse or attending physiciancontacts the on-call provider bysimply clicking the icon symbolnext to the on screen call order,which automatically links to thedevice number of the provider andsends the message to the provider.While the actual device number isnot visible on screen, in theevent the Parkland on-linedirectory and on-call system isunavailable, the Parkland PageOperator can complete manual pageof the on-call physician. In theevent Parkland experiences atelephone outage and the pageoperator is not available, anEmergency Response Code YellowTelecommunications would beactivated in accordance withParklands Emergency OperationsR

CMS Report and Parkland Action Plan

Documents

Transcript of CMS Report and Parkland Action Plan