HospitalInspections.org

Based on document review and interview, the facility failed to document the time when the patient consent for treatment was obtained and verify that consent was obtained before medical care and treatment was provided for 16 of 16 medical records (MR) reviewed.

Findings:

1. The policy/procedure Entries in the Medical Record (reviewed 12-12) indicated the following: "All entries must be legible and complete, and must be signed, dated and timed promptly ..."
2. The policy/procedure Consent (reviewed 2-13) indicated the following: "An Authorization for Treatment document must be signed and dated before medical and surgical treatment or procedures may be started on any patient, except in emergency cases." The policy/procedure failed to indicate a requirement to time the authorization for treatment (or consent) when signed and dated by the patient or patient's representative and signed, dated and witnessed by the facility representative.
3. The MR for patients 20, 21, 22, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 and 36 failed to document a time when the Authorization for Medical/Surgical Treatment was signed and dated by the patient or patient's representative and signed, dated and witnessed by the facility representative authorized to obtain consent. The MR for patient 22 failed to indicate that a witness signed or dated the Authorization for Medical/Surgical Treatment when signed by the patient or patient's representative.

4. During an interview on 12-04-14 at 1020 hours, the nurse informaticist A7 confirmed that the consent policy/procedure lacked a requirement to time the consent when signed and dated.

5. During an interview on 12-04-14 at 1430 hours, the director of intensive care A1 assisting with the MR review confirmed that the 16 patient records titled Authorization for Medical/Surgical Treatment lacked documentation indicating the time when dated and signed.

Based on document review and interview, the facility failed to ensure that the medical record (MR) was complete and included documentation of a discharge summary for 1 of 16 (patient 27) MRs reviewed.

Findings:

1. The policy/procedure Medical Staff Record Completion (reviewed 2-13) indicated the following: "Discharge summaries are required on all inpatient and observation records."

2. The MR for patient 27 failed to indicate that a discharge summary was present in the MR.

3. During an interview on 12-04-14 at 1330 hours, the nurse informaticist A7 confirmed that the MR for patient 27 lacked a discharge summary.

Based on document review and interview, it could not be determined for 7 of 7 pieces of radiology equipment were being operated in accordance with accepted standards of practice (manufacturer recommendations of operation).

Findings:

1. On 12-1-14 at 12:30 pm, employee #A2, Chief Executive Officer, was requested to provide documentation that the following pieces of diagnostic radiology equipment were being operated in accordance with manufacturer recommendation, either via policy or the actual manuals of manufacturer recommendations of operation:
C-arm
Fluoroscopic machine
Computer tomography scanner
Mammography machine
Nuclear Medicine machine
Magnetic Resonance Imaging machine
Ultrasound machine

2. In interview, on 12-3-14 at 3:10 pm, employee #A11, Director of Radiology, indicated there was no such policy nor manufacturer ' s manuals available and no other documentation was provided prior to exit.

King's Daughters' Health is comprised of the main hospital in Madison, IN (Building 02), the outpatient rehabilitation services building in Madison, IN (Building 03), the rehabilitation services building in Versailles, IN (Building 04), the rehabilitation therapy building in Vevay, IN (Building 05) and the oncology office in Madison, IN (Building 06). Building 02 was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.41(b), Life Safety from Fire and the 2000 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC) Chapter 18, New Health Occupancies; Building 03 was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.41(b), Life Safety from Fire and the 2000 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC) Chapter 39, Existing Business Occupancies, Building 04 was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.41(b), Life Safety from Fire and the 2000 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC) Chapter 39, Existing Business Occupancies, Building 05 was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.41(b), Life Safety from Fire and the 2000 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC) Chapter 39, Existing Business Occupancies, and Building 06 was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.41(b), Life Safety from Fire and the 2000 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC) Chapter 38, New Business Occupancies.

Building 02 is a four story fully sprinkled building of Type II (222) construction with a basement and has a fire alarm system with smoke detection in the corridors and spaces open to the corridors. Building 02 provides overnight care. Building 02 has a capacity of 86 beds and had a census of 44 at the time of this survey.

Building 03 is a one story fully sprinkled building of Type V (000) construction and has a fire alarm system with smoke detection in the corridors. Building 03 provides services during regular business hours with no overnight stays.

Building 04 is a one story partially sprinkled building of Type V (000) construction with a basement and has no fire alarm system. Building 04 provides services during regular business hours with no overnight stays. (Note: The basement is sprinkled.)

Building 05 is a one story fully sprinkled building of Type V (000) construction and has a fire alarm system with smoke detection in the corridor. Building 05 provides services during regular business hours with no overnight stays.

Building 06 is a one story fully sprinkled building of Type V (000) construction and has a fire alarm system with no smoke detection. Building 06 provides services during regular business hours with no overnight stays.

Based on Life Safety Code survey and deficiencies found (see 2567L), it was determined that the facility failed to ensure 2 of 21 room wall and ceilings in the outpatient rehabilitation services building (Building 03) were provided with an interior finish with a flame spread rating of a class A, class B, or class C, failed to ensure 3 of 17 room walls and ceilings in the rehabilitation services building (Building 04) were provided with an interior finish with a flame spread rating of a class A, class B, or class C (see K 015), failed to ensure 4 of 4 open use areas (Building 02) were separated from the corridor by walls constructed with at least a thirty minute fire resistance rating extending from the floor to the roof/floor above or met an Exception (see K 017), failed to ensure 1 of over 50 sprinklered hazardous areas/rooms, such as the Material Management Intake area (Building 02), an area/room over 50 square feet containing combustible material, was separated from other spaces by smoke resisting partitions and doors, failed to ensure 1 of over 50 hazardous area room doors, such as a kitchen door (Building 02), was equipped with a self closing device on the door (see K 029), failed to ensure 1 of 1 basement combustible liquid storage room (Building 02) was provided with an approved storage cabinet (see K 135) and failed to ensure 1 of 1 emergency generator with over 100 horsepower in the King's Daughters' Health hospital building (Building 02) was equipped with a remote manual stop (see K 144).

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 observation, document review and interview, the facility failed to ensure maintainence of the facility such that the safety of patients was assured in 2 instances.

Findings:

1. On 12-1-14 at 2:20 pm in the presence of employee #A5, Plant Director, it was observed in the Environmental Storage Room, there were the following paper-goods items stored on open shelves with no covering, subjecting them to dust and dirt contamination:

Large rolls toilet paper - 143 rolls
Small rolls toilet paper - 1537 rolls
C-fold hand towels - 81 packages
Large roll hand towels - 433

2. Review of a document entitled Food and Nutrition Services - Policy Requirements - Food Preparation and Storage in Patient Areas, reviewed/revised 3/14, indicated all expired products will be discarded.

3. On 12-1-14 at 4:25 pm in the presence of employee #A5, it was observed in a refrigerator in the Cardiopulmonary area, there were 18, 4-ounce cartons of orange juice with an expiration date of 10-28-14.

4. In interview, on 12-4-14 at 12:10 pm, employee #A13, Director of Nutrition, confirmed the above-stated policy and outdated orange juice.

Based on observation and interview, the facility failed to ensure 2 of 21 room wall and ceilings in the outpatient rehabilitation services building (Building 03) were provided with an interior finish with a flame spread rating of a class A, class B, or class C, failed to ensure 3 of 17 room walls and ceilings in the rehabilitation services building (Building 04) were provided with an interior finish with a flame spread rating of a class A, class B, or class C, failed to ensure 4 of 4 open use areas (Building 02) were separated from the corridor by walls constructed with at least a thirty minute fire resistance rating extending from the floor to the roof/floor above or met an Exception, failed to ensure 1 of over 50 sprinklered hazardous areas/rooms, such as the Material Management Intake area (Building 02), an area/room over 50 square feet containing combustible material, was separated from other spaces by smoke resisting partitions and doors, failed to ensure 1 of over 50 hazardous area room doors, such as a kitchen door (Building 02), was equipped with a self closing device on the door, failed to ensure 1 of 1 basement combustible liquid storage room (Building 02) was provided with an approved storage cabinet and failed to ensure 1 of 1 emergency generator with over 100 horsepower in the King's Daughters' Health hospital building (Building 02) was equipped with a remote manual stop (see K 144).

Findings:

1. Observation with SD#1, the senior director on 12/03/14 during a tour of the facility from 10:50 a.m. to 12:40 p.m., the outpatient rehabilitation services building (Building 03) indicated a forty foot by thirty foot south wall in the athletic strengthening gymnasium with no interior finish and no interior finish on the ceiling in the swimming pool pump room.

2. The lack of an interior finish in the outpatient rehabilitation services building athletic strengthening gymnasium south wall and swimming pool pump room ceiling was verified by SD#1 at the time of observation and acknowledged at the exit conference on 12/04/14 at 2:20 p.m.

3. Observation with plumber #1 on 12/03/14 from 8:00 a.m. to 10:00 a.m. indicated the rehabilitation services building (Building 04) basement furnace room and basement mechanical room lacked interior finish on the ceilings, with two by twelve floor joists exposed. Furthermore, the basement furnace room north wall had a two foot by three foot square section of drywall missing above the main electrical panel.

4. The lack of a ceiling interior finish in the basement furnace room and basement mechanical room and missing drywall above the main electrical panel north wall was verified by plumber #1 at the time of observations and acknowledged by SD#1 at the exit conference on 12/04/14 at 2:20 p.m.

5. Observations on 12/02/14 between 10:00 a.m. and 2:00 p.m. during a tour of the facility (Building 02) with FOM#1, the Facility Operations Manager, indicated the following areas were open to the corridor:
1. The fourth floor Waiting Room
2. The third floor Waiting Room
3. The second floor Sitting Area
4. The second floor Material Management Intake area

6. Exception #1 requirement (c) of LSC 18.3.6.1 was not met as follows: The third and fourth floor Waiting Rooms, the second floor Sitting Area, and the second floor Material Management Intake area were not protected by an electrically supervised automatic smoke detection system, or the entire spaces were not arranged and located to allow direct supervision by the facility staff from nurses' stations or similar staffed spaces.

7. This was acknowledged by FOM#1 at the time of each observation.

8. Observation on 12/02/14 at 12:40 p.m. during a tour of the facility (Building 02) with FOM#1 indicated the Material Management Intake area/room was open to the corridor. This area was filled with over 25 hard plastic medical storage totes, cardboard boxes, and other items.

9. This was acknowledged by FOM#1 at the time of observation.

10. Observation on 12/02/14 at 1:30 p.m. during a tour of the facility (Building 02) with FOM#1 indicated the kitchen dishwashing room door to the dining room was not provided with a self closing device.

11. This was acknowledged by FOM#1 at the time of observation.

12. Observation with SD#1 on 12/02/14 at 12:50 p.m. indicated the basement flammable storage room (Building 02) had ninety six gallons of xylene, which was labeled as a Class II flammable liquid, stored in one gallon containers and in cardboard boxes on wooden pallets. Furthermore, the flammable storage room measured seven hundred twelve square feet. Based on the measurement of the room, the maximum amount of xylene allowed to be stored in the open, outside of an approved storage cabinet, is seven gallons.

13. The lack of storage cabinets for the ninety six gallons of flammable liquid xylene was verified by SD#1 at the time of observation and acknowledged at the exit conference on 12/04/14 at 2:20 p.m.

14. Observation on 12/02/14 at 1:30 p.m. with SD#1 indicated the emergency generator, located in the front of the main hospital building, was in an enclosure and was equipped with a manual stop switch mounted on the emergency generator, but not at a remote location.

15. This was verified by SD#1 at the time of observation and acknowledged at the exit conference on 12/04/14 at 2:20 p.m.

Based on observation, the facility placed 1 alcohol-based hand sanitizer (ABHS) on a wall in such a manner as to cause a fire hazard.

Findings:

1. On 12-1-14 at 4:15 pm, in the presence of employee #A5, Plant Operations Director, it was observed in the Cardiopulmonary waiting area, there was 1 ABHS on a wall directly over an electrical outlet. Its location directly over an electrical ignition source posed a fire hazard if the flammable alcohol was sprayed or dropped into the electrical ignition source.