HospitalInspections.org

Based on observation and staff interviews the facility failed to construct, install and maintain the building systems to ensure a physical environment that was safe for patients and staff. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-0133 - Multiple Occupancies-Construction Type
K-0321 - Hazardous Areas
K-0345 - Fire Alarm - Testing And Maintenance
K-0352 - Sprinkler System - Supervisory Signals
K-0353 - Sprinkler System - Maintenance And Testing
K-0363 - Corridor - Doors
K-0712 - Fire Drills
K-0918 - Electrical Systems - Essential Electric System Maintenance and Testing

Based on record review, observation, and interview, staff failed to follow policy to ensure patient safety by not performing daily monitoring of medical equipment and properly labeling equipment in 3 of 7 patient care departments (Emergency Department, Infusion Center, Medical/Surgical Unit).

Findings include:

Per review on 6/5/2018 at 10:45 PM pf policy titled, "Blanket and Fluid Warmer" #180-308, 10/2017 revealed, "2. Warming cabinets will be labeled on the outside of the cabinet to identify the contents. 3. Warming cabinets will be labeled with appropriate temperature range for its content. 4. Ongoing temperature monitoring of blanket warmers will be performed by staff working in the vicinity by visual observation of posted maximum temperature and temperature display.

Per observation on 6/4/2018 at 12:00 PM in the Emergency Department, noted a blanket warmer with a digital temperature reading of 134 degrees. There was no label on the outside of the cabinet to identify the content and there was no label indicating the appropriate temperature range for its content.

Per observation on 6/5/2018 at 11:40 PM, in the Infusion Department, noted a warming cabinet with a digital temperature of 130 degrees. There was no label on the outside of the cabinet to identify the contents.

During observations of the Medical Surgical Unit on 6/4/18 at 12:10 AM with Director of Medical Floor C, the temperature of the blanket warmer in the clean supply room was 131 degrees Fahrenheit. There is no documented acceptable temperature range on the blanket warmer for staff to check before obtaining a blanket and there was no documentation of the blanket warmer being checked for approved/safe temperature.

The above deficiency was confirmed in interview with Director of Medical Floor C at the time of observation who stated "We don't check the temperature on a regular basis."

Per interview on 6/4/2018 at 12:10 PM, Registered Nurse G stated, "We are only allowed to put blankets in this warmer, but I am not sure what the acceptable temperature should be between."




37420

Based on observation, and staff interviews, the facility failed to construct, install and maintain the building systems to ensure life safety from fire. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-0133 - Multiple Occupancies-Construction Type
K-0321 - Hazardous Areas
K-0345 - Fire Alarm - Testing And Maintenance
K-0352 - Sprinkler System - Supervisory Signals
K-0353 - Sprinkler System - Maintenance And Testing
K-0363 - Corridor - Doors
K-0712 - Fire Drills
K-0918 - Electrical Systems - Essential Electric System Maintenance and Testing

Based on record review and interview the facility failed to reassess pain levels after pain medication were provided to 3 of 20 patient medical records reviewed (Patient #1, 13 and 16).

Finding include:

Reviewed facility policy titled "Pain Management Policy" on 6/5/18 at 12:00 PM. This document states "Acute pain is reassessed and documented within thirty to sixty minutes after medication and/or alternative treatment administered."

Review of Patient #1 medical record on 6/4/2018 at 1:30 PM, Patient # 1 was admitted on 6/1/18 for chief complaint hypotension and weakness. On 6/4/18 at 2:02 PM, Patient #1 was provided analgesic for complaint of pain. There is no documentation that pain level was reassessed until 6:30 PM which is 4 hours after analgesic was given.

Review of Patient #16 medical record on 6/5/2018 at 2:00 PM, Patient # 16 was admitted on 4/19/18 for cellulitis. On 4/20/18 at 2:13 PM, Patient #16 was provided analgesic for complaint of pain. There is no documentation that pain level was reassessed for effectiveness.

The above deficiency was confirmed with Director of Medical Floor C on 6/4/18 at time of record review. Director of Medical Floor C stated "Yes, it looks like the reassessment wasn't within an hour."







29963


Review of Patient #13's medical record on 6/4/2018 at 9:23 AM, Patient #13 was admitted on 4/14/18 for chief complaint of shaking and chills. Patient #13 has a current diagnosis of Squamous Cell Carcinoma of the left lower lobe, Pneumonia, Chronic Obstructive Pulmonary Disease. On 4/15/2018 at 8:59 AM and 4:09 PM , 4/16/2018 at 9:30 AM and 4:52, and 4/17/2018 at 2:15 PM Patient #13 was provided analgesic for complaint of pain. There was no documentation that pain level was reassessed following administration of pain medication.




32670

Based on record review, observation, and interview, the facility failed to secure medical records in 1 of 2 areas (basement storage room) from unauthorized access.

Findings include:

Per review on 6/5/2018 at 12:00 PM of policy titled, "Retention and Destruction of Medical Records" #390-003, dated 1/2017 revealed, "Medical records will be maintained in a secure, locked file room."

Per observation on 6/5/2018 at 9:00 AM of a storage area in the basement where medical records are stored. The medical records were intermingled in the large room containing numerous supplies including paint cans, replacement filters, plastic containers filled with books, chairs, tables, Christmas decorations, privacy curtain, and numerous other supplies.

During an interview on 6/5/2018 at 9:05 AM, Health Information Director I stated, "There are 4 maintenance employees who have a key and can access the storage room containing the medical records."