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Based on Life Safety Code (LSC) survey, Parkview Lagrange Hospital was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 485.623(d), Life Safety from Fire and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 18, New Health Care Occupancies.

This two story facility with a basement was determined to be of Type II (111) construction and was fully sprinklered with the exception of two elevator machine rooms. The facility has a fire alarm system with smoke detection in the corridors and spaces open to the corridors with the exception of the second floor work area. The facility has a capacity of 25 and had a census of 16 at the time of this survey.

Based on LSC survey and deficiencies found (see CMS 2567L), it was determined that the facility failed to ensure a separation from 1 of 1 nonconforming buildings by a fire barrier having at least a two hour fire resistance rating (see K 011), failed to ensure 1 of 1 second floor work rooms was separated from the corridor by a partition capable of resisting the passage of smoke as required in a sprinklered building, or met an Exception (see K 017), failed to ensure the corridor doors to 4 of 4 CCU rooms and 2 of 2 operating rooms positively latched into the door frame (see K 018), failed to maintain the vertical opening protection of 2 of 3 exit stairwells (see K 020 and K 033), failed ensure 2 of 3 vertical exit egress towers provided a means of egress which discharged to the exterior or the public way (see K 032), failed to ensure a complete automatic sprinkler system was provided for 2 of 2 elevator equipment rooms and 3 of 3 second floor housekeeping closets (see K 056), failed to ensure 1 of 1 kitchen range hood's fire extinguishing equipment was inspected and approved every 6 months by properly trained and qualified persons (see K 069), failed to provide the complete documentation for testing 1 of 1 emergency generators providing power to the emergency power system and failed to ensure 1 of 1 emergency generators was provided with an alarm annunciator in a location readily observed by operating personnel at a regular work station such as a nurse station (see K 144) and failed to ensure 1 of 1 flexible cords was not used as a substitute for fixed wiring to provide power for medical equipment or equipment with a high current draw (see K 147).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on policy and procedure review, observation, document review, and interview, the nursing staff failed to implement policies related to cleanliness of units.

1. review of the policy and procedure "Warming Cabinets" "General Safety" (no policy number), last approved on 4/30/13, indicated:
a. on page two under "Procedure", section "F. Cleaning", it reads: "Departments will be responsible for monthly cleaning of the warming devices. This will be logged on the Warming cabinet cleaning Log..."

2. at 3:45 PM on 12/17/13, while on tour of the ED (emergency department) in the company of staff member #63, the ED manager, it was observed that there was an accumulation of dust on the lower shelf of the bottom cabinet of the Amsco blanket warmer

3. at 3:45 PM on 12/17/13, the document posted on the Amsco blanket warmer in the ED indicated cleaning for the blanket warmer was done on an annual basis and was last cleaned on 11/26/12

4. interview with staff member #63 at 3:45 PM on 12/17/13 indicated the ED staff clean the blanket warmer on an annual basis, while the facility policy indicates a monthly cleaning will occur

5. at 2:10 PM on 12/18/13, while on tour of the FBC (family birthing center) in the company of staff member #68, the RN (registered nurse) manager, it was observed in the crash cart that:
a. there was a large accumulation of dust on the top of the cart
b. an Insyte (intravenous start needle system) had expired 8/13 and another had expired 10/13 (top drawer of the crash cart)

6. review of the "Defibrillator and Code Cart Checklist" for December 2013 and November 2013 indicated daily checks of the cart had occurred, but no cleaning was checked/documented on the forms

7. review of the "Crash Cart Log 2013" document, provided by the ED manager, indicated the FBC crash cart was cleaned in October and November (exact dates not noted/provided)

8. interview with staff member #68 at 2:10 PM on 12/18/13 indicated:
a. the monthly cleaning also includes checking for expiration dates on all products/items within the cart
b. staff doing monthly cleaning have failed to clean the top of the cart
c. staff doing monthly cart checks have failed to ensure the removal of expired products, as listed in 8. above

Based on review of manufacturer's instructions, observation, and staff interview, the hospital failed to ensure 3 of 3 bottles of Osmolite and 4 of 4 bottles of Jevity were stored in accordance with manufacturer's instructions.

Findings include:

1. On 12-19-13 between 12:30 PM and 1:30 PM, review of manufacturer's instructions revealed the following:
a. The label on a 1.1 quart bottle of "Osmolite 1 Cal Complete Balanced Nutrition Without Fiber" read: "Contains light-sensitive nutrients."
b. The label on a 1.6 quart bottle of "Jevity 1 Cal Complete, Balanced Nutrition With Fiber" read: "Contains light-sensitive nutrients."

2. On 12-19-13 between 12:30 PM and 1:30 PM, three 1.1 quart bottles of "Osmolite 1 Cal Complete Balanced Nutrition Without Fiber" and four 1.6 quart bottles of "Jevity 1 Cal Complete, Balanced Nutrition With Fiber" were observed on a shelf in the dry storage room in the kitchen, exposed to light.

3. In interview, on 12-19-13 between 12:30 PM and 1:30 PM, Staff Members #L7 and #L8 acknowledged the Osmolite and Jevity should be stored so that they are not exposed to light.

Based on observation, interview and record review, it was determined that the facility failed to ensure a separation from 1 of 1 nonconforming buildings by a fire barrier having at least a two hour fire resistance rating, failed to ensure 1 of 1 second floor work rooms was separated from the corridor by a partition capable of resisting the passage of smoke as required in a sprinklered building, or met an Exception, failed to ensure the corridor doors to 4 of 4 CCU rooms and 2 of 2 operating rooms positively latched into the door frame, failed to maintain the vertical opening protection of 2 of 3 exit stairwells, failed ensure 2 of 3 vertical exit egress towers provided a means of egress which discharged to the exterior or the public way, failed to ensure a complete automatic sprinkler system was provided for 2 of 2 elevator equipment rooms and 3 of 3 second floor housekeeping closets, failed to ensure 1 of 1 kitchen range hood's fire extinguishing equipment was inspected and approved every 6 months by properly trained and qualified persons, failed to provide the complete documentation for testing 1 of 1 emergency generators providing power to the emergency power system and failed to ensure 1 of 1 emergency generators was provided with an alarm annunciator in a location readily observed by operating personnel at a regular work station such as a nurse station and failed to ensure 1 of 1 flexible cords was not used as a substitute for fixed wiring to provide power for medical equipment or equipment with a high current draw.

Findings:

1. Observation during a tour of the facility with MSS1 and SC1 on 12/18/13 at 2:40 p.m. indicated the hospital, a two story building of Type II (111) construction was connected to a two story medical office building of Type V (000) construction and lacked a fire barrier separation having at least a two hour fire resistance rating.

2. In interview at the time of observation, MSS1 confirmed the lack of a two fire barrier separation and indicated the hospital had a variance when the hospital was constructed and installed additional sprinklers where the two hour fire barrier would be.

3. Observation with SC1 on 12/19/13 at 10:20 a.m. indicated the second floor work area around the corner from the medical/surgery nurse station lacked a corridor door and the second floor work area was not protected by an electrically supervised automatic smoke detection system.

4. This was acknowledged by SC1 at the time of observation.

5. Observation with SC1 on 12/19/13 between 9:57 a.m. and 11:57 a.m. indicated the corridor door to the patient rooms in CCU and the two operating room corridor doors were designed with double corridor doors. One door was equipped with a manual latching device that would latch into the door frame and the remaining door was designed to latch into the stationary door. Each door could not latch automatically, and independent of the other door, into the door frame.

6. This was acknowledged by SC1 at the time of observations.

7. Observation on 12/19/13 with MSS1 during the tour from 9:30 a.m. to 11:00 a.m. indicated the center first floor, terrace level stairwell doors and the south second floor stairwell door lacked a door label indicating a fire resistance rating.

8. In interview during the observations, MSS1 acknowledged the stairwell doors were missing fire door labels and indicated documentation showing the stairwell exit doors provided at least a one hour fire resistance rating was not available.

9. Observation on 12/19/13 with MSS1 during the tour from 9:30 a.m. to 11:00 a.m. indicated the north and center exit stairs did not discharge directly to the exterior or through an approved exit passageway at the first floor level.

10. Interview with MSS1 on 12/19/13 from 9:30 a.m. to 11:00 a.m. confirmed the north and center exit stairs did not discharge directly to the exterior or through an approved exit passageway at the first floor level.

11. Observation with SC1 on 12/19/13 from 9:45 a.m. to 10:22 a.m. indicated all three second floor housekeeping closets lacked sprinkler coverage.

12. This was acknowledged by SC1 at the time of observation.

13. Observation during a tour of the facility on 12/18/13 from 2:15 p.m. to 3:45 p.m. with MSS1 and SC1 indicated both elevator machine rooms lacked sprinkler coverage.

14. In interview with MSS1 on 12/18/13 at 2:00 p.m., it was acknowledged the basement service elevator and main elevator machine rooms lacked sprinkler coverage.

15. Review of the kitchen range hood suppression system testing documentation with MSS1 and SC1 from 11:45 a.m. to 2:15 p.m. on 12/18/13 indicated a range hood fire suppression equipment inspection was last performed by the facility's vendor on 05/06/13.

16. In interview at the time of record review, MSS1 acknowledged the 05/06/13 inspection was the most recent kitchen range hood fire suppression equipment inspection.

17. Review of the "Generator Weekly Load Test" log with MSS1 on 12/18/13 at 1:30 p.m. indicated the weekly load test log indicated the transfer of power from the main source to the emergency generator but lacked documentation of the length of time for generator to start and transfer power.

18. In interview at the time of record review, MSS1 acknowledged the length of time for the generator to start and transfer power was generally 10 seconds or less but it was not documented.

19. Observation on 12/19/13 during the tour from 9:30 a.m. to 11:00 a.m. with MSS1 indicated a remote alarm annunciator for the generator was provided in the maintenance shop.

20. In interview at the time of observation, MSS1 stated the maintenance shop is not staffed from 11:30 p.m. to 4:00 a.m. but has security office checking the area on an hourly basis.

21. Observation with SC1 on 12/19/13 at 10:35 a.m. indicated a refrigerator was supplied electricity by an extension cord power strip in the therapy department storage room.

22. Interview with SC1 on 12/19/13 at 10:35 a.m. confirmed a refrigerator was supplied electricity by an extension cord power strip in the therapy department storage room.

Based on policy and procedure review, observation and interview, the nursing staff failed to implement policies related to expired glucometer control solutions.

Findings:
1. review of the policy and procedure "Whole Blood Glucose - AccuChek Inform Meter", policy number 4002, with a most recent revised date of 2/2012, indicated:
a. on page three under "III. Equipment and Materials", in section E., it reads: "Storage Requirements:...Glucose Control Solutions...are stable for three months after opening or until the expiration date on vials, whichever comes first. Three month expiration date must be written on vials after opening."

2. at 3:50 PM on 12/17/13, while on tour of the ED in the company of staff member #63, the ED manager, it was observed that the glucometer control solution vials (two vials) had opened dates of 9/1/13 and expiration dates written on them of 12/1/13

3. at 3:50 PM on 12/17/13, the ED manager (staff member #63) confirmed that the glucometer control solutions were expired per documentation on the vials

Based on policy and procedure review, patient medical record review, and staff interview, the facility failed to implement its policy related to dietician consultations for one patient (pt.#8), and failed to ensure the documentation of ordered nutritional supplements by nursing staff for four patients (pts. #4, #6, #8, and #9).

Findings:
1. Review of the policy and procedure titled "Nutrition Care Process - Adult" "Clinical Nutrition Care" (no policy number), last approved 4/2013, indicated:
a. under "Policy Statement", it reads: "The registered Dietitian (R.D.) or assigned designee is available to initiate nutrition care process or to provide consultation within 24 hours of receipt of consult."
b. under "Procedures", it reads: "1. Nutrition Care Process will be initiated by an RD upon receipt of consult. The Registered Dietitian will be available to initiate nutrition care process seven days a week 7:00 A.M. - 7:00 P.M. either in house or on call status."

2. review of patient medical records indicated patient #8:
a. had an order written at 6:07 AM on 9/26/13 for a dietary consult
b. had a dietary consult performed at 5:57 PM on 9/30/13

3. interview with staff member #67, RN (registered nurse) and med/surg manager, at 1:40 PM on 12/19/13 indicated:
a. the RD was away the time frame between 9/26/13 and 9/30/13 (for their wedding)
b. there was no back up for dietary consultations, or there was a lack of communication in this regard
c. the policy requiring a dietary consult, within 24 hours of an order for a consult, was not followed for pt. #8

4. review of patient medical records indicated:
a. pt. #4 was admitted 11/21/13 and had:
A. orders for tube feedings with TwoCal at 250 cc every 6 hours while awake
B. no documentation of feedings for 2 of 4 feedings on 11/22/13 and no documentation of feedings for 1 of 4 feedings on 11/23/13 (discharge was on 10/25/13)
b. pt. #6 had:
A. an order for ensure bid (two times/day) between meals written 11/20/13 that was changed to health shakes bid between meals on 11/21/13
B. no documentation of a nutritional supplement for 1 of 2 feedings on 11/20/13 and no documentation for 2 of 2 feedings for 11/21/13, and 11/22/13 (discharge was on 11/23/13)
c. pt. #8 had:
A. an order for ensure plus tid (three times a day) with meals ordered at 5:57 PM on 9/30/13
B. no documentation of feedings for 1 of 3 on 10/1/13, for 2 of 3 feedings on 10/2/13, and for 1 of 3 feedings on 10/3/13 (discharge was 10/4/13)
d. pt. #9 had:
A. an order for Resource Health Shake bid with meals ordered 10/20/13
B. no documentation of feedings for 3 of 3 on 10/21/13; 2 of three feedings on 10/22/13; 1 of 3 feedings on 10/23/13; 3 of 3 on 10/24/13; 2 of 3 feedings on 10/25/13; 3 of 3 feedings on 10/26/13 and 10/27/13; 1 of 3 feedings on 10/28/13; 3 of 3 on 10/29/13; 2 of 3 on 10/30/13, 10/31/13, and 11/1/13; 1 of 3 feedings on 11/2/13 and 11/3/13; for 2 of 3 feedings on 11/5/13; 1 of 3 feedings on 11/6/13; and 3 of 3 feedings on 11/7/13 (discharged on 11/8/13)

5. interview with staff member #67, RN and med/surg manager, at 1:40 PM on 12/19/13 indicated:
a. the medical records listed in 4. above were lacking documentation as stated in the "nutritional supplement" section of the I & O (intake and output) area of the medical record
b. it could be that nursing staff are documenting nutritional supplement in some other area of the I & O section, but not in the nutritional supplement area
c. it cannot be determined that nursing is offering, or that patients are consuming, nutritional supplements with the lack of documentation either in the I & O section of the medical record, or with any other nursing notes

Based on policy and procedure review, patient medical record review, and staff interview, the facility failed to implement its policy related to interdisciplinary team composition and attendance at care conferences for 3 of 6 patients who were in swing bed status long enough for a care conference to occur (pts. #1, #3, and #7).

Findings:
1. review of the policy and procedure "Care Conference" "Patient Care", (no policy number), with a last approval date of 6/30/13, indicated:
a. under item "II. Policy Statement", it reads: "A. A conference will be held on a weekly basis to review patients that are currently on Swing Bed status. B. Those attending will be: 1. Swing Unit Medical Director 2. Case Management 3. Pharmacy 4. Social Services/Discharge Planner 5. Dietician when available 6. Rehab. Therapies as appropriate..."

2. review of patient medical records indicated:
a. pt. #1 had a care plan meeting/conference on 12/1/13 that lacked documentation of attendance by the Swing Bed unit medical director, and case management personnel
b. pt. #3 had a care plan meeting/conference on 12/12/13 that lacked documentation of attendance by the social services/discharge planner
c. pt. #7 had a care plan meeting/conference on 10/16/13 that lacked documentation of attendance by the social services/discharge planner

3. interview with staff member #67, RN (registered nurse) and med/surg manager, at 1:05 PM on 12/19/13 indicated:
a. there is rarely a time that the medical director and discharge planner are not in attendance at the care conferences
b. it was thought that staff are failing to sign in on the electronic record that they attended the care conference
c. therapy staff have also been delinquent in signing in electronically when attending care conference meetings making it appear as though they did not attend