HospitalInspections.org

Based on the Life Safety Code inspection conducted on 08/22/12, it was determined that the hospital failed to meet the Condition of Participation for the Physical Environment as evidenced by non compliance with the following:

The hospital failed to:

K018 Standard: Maintain corridor doors to resist the passage of heat/smoke.

K025 Standard: Fill penetrations in the smoke barrier.

K027 Standard: Maintain the self closing/automatic-closing doors in the smoke barrier.

K029 Standard: Maintain the integrity, smoke resistance, of doors in hazardous areas.

K039 Standard: To keep exits readily accessible at all times.

K050 Standard: To conduct the required fire drills.

K062 Standard: Maintain the sprinkler heads and assure that all parts of the sprinkler system were in accordance with the UL Listing.

K076 Standard: Separate empty and full medical gas cylinders.

K144 Condition of Participation: To document the required testing of the emergency generator.

K147 Standard: To provide protection from electrical shock and allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances.

The cumulative effect of these systemic practices resulted in the failure of the Hospital to ensure compliance with the provisions for the Physical Environment.

Based on observation and interview, it was determined that the chief executive officer failed to be responsible for managing the Hospital, when an employee used a sleep laboratory simulated bedroom and patient bathroom, in lieu of a hotel room.

Findings include:

Tour was conducted of the sleep laboratory on 08-14-12. Tour revealed two simulated "bedrooms," in which sleep studies were performed on patients. Tour revealed that in the second "bedroom," personal clothing items were hanging on the bathroom door. Additional personal items, such as a backpack and hairdryer, were observed in the patient bathroom adjoining the simulated bedroom.

The Director of Respiratory Therapy acknowledged, during interview conducted on 08-14-12, that an employee was using the sleep lab simulated bedroom and adjoining patient bathroom in lieu of renting a hotel room. The Director of Respiratory Therapy acknowledged that an employee using the sleep laboratory was an inappropriate use of the licensed sleep laboratory.

Based on review of hospital policies/procedures, patient medical records and interviews with patients and staff, it was determined that the hospital failed to require that all patients were advised of their rights, as demonstrated by five of five (5 of 5) Emergency Room (ER) Outpatients' medical records had no documentation that the patient was provided a copy of the Patient Rights.

Findings include:

Review of the hospital Admitting policy and procedure Patient Rights revealed, "...MGRMC (Mt Graham Regional Medical Center) Hospital and medical staff have adopted the following statement of patient rights. This list shall include but not be limited to the patient's right to: Become informed of his or her rights as a patient in advance of...the provision of care..."

Review of the hospital Admitting policy and procedure for patient registration revealed, "...Upon admission all patients are given a comprehensive brochure that outlines Mt Graham Regional Medical Center's services and ...patient rights and responsibilities..."

The Director of Admissions confirmed on interview that the above quoted policies and procedures were effective and in use at the time of the survey.

Patient #1, interviewed on 08/13/2012 at 2 p.m. indicated that he had not received a copy of the patient rights. Review of the patient's medical record revealed no written acknowledgement of having received a copy of the patient rights during that ER admission.

Patient #2, interviewed on 08/13/2012 at 2:30 p.m. indicated that she had not received a copy of the patient rights. Review of the patient's medical record revealed no written acknowledgement of having received a copy of the patient rights during that ER admission.

Patient #3 was admitted to the ER on 06/16/2012 .Review of the patient's medical record revealed no written acknowledgement of having received a copy of the patient rights during that ER admission.

Patient #4 was admitted to the ER on 3/10/2012. Review of the patient's medical record revealed no written acknowledgement of having received a copy of the patient rights during that ER admission.

Patient #5 was admitted to the ER on 3/12/2012. Review of the patient's medical record revealed no written acknowledgement of having received a copy of the patient rights during that ER admission.

Employee #1 was interviewed on 08/13/2012 at 3:00 p.m. and confirmed that during the registration process for ER patients they are not given a copy of the Patient Rights.

Based on observation, document review, and interview, it was determined that the Hospital failed to require that in-house preparation of radio pharmaceuticals was conducted by, or under the direct supervision of a trained registered pharmacist or a physician.

Findings include:

Tour was conducted of the nuclear medicine laboratory in the radiology department on 08-15-12. Observation during tour revealed that radio pharmaceuticals are prepared in the hospital nuclear medicine laboratory by Certified Nuclear Medicine Technologist #1, and Certified Nuclear Medicine Technologist #2. There was no appropriately trained registered pharmacist, or a doctor of medicine or osteopathy providing direct supervision.

Documentation provided by the Director of Imaging revealed: "Our trained, certified nuclear medicine technologists prepare some radio-pharmaceuticals using technetium..."

The Director of Imaging acknowledged, during interview conducted on 08-15-12, that Certified Nuclear Medicine Technologists were preparing radio pharmaceuticals without the direct supervision of an appropriately trained registered pharmacist, or a doctor of medicine or osteopathy, as required.